Laser ablation of posterior nasal nerves for rhinitis.

BACKGROUND: Posterior nasal nerve (PNN) surgery, Radiofrequency (RF), and cryoablation have been described as alternative treatments for allergic and vasomotor rhinitis. We hypothesize that endoscopic (diode) laser ablation (ELA) is effective and less invasive than previously described methods. METHODS: An IRB approved prospective study was performed. Thirty-two patients with chronic rhinitis and nasal congestion resistant to medical management were recruited. Total Nasal Symptom Score (TNSS) measurements were used to assess symptom severity and treatment outcomes. ELA was performed bilaterally in the clinic with a 940 nm diode laser with CW 5 W output, under topical/local anesthesia in 21 patients, while the remaining 11 were treated under sedation in the operating room. The 400-micron uninitiated diode laser fiber tip with a malleable protective shaft was specially designed for PNN ablation. The fiber was pre-shaped according to the intranasal anatomy and endoscopically advanced toward the posterior middle meatus. Patients were followed up for the first 90 days after treatment. RESULTS: ELA was successfully completed in 97% of patients. No crusting, epistaxis, or other complications were observed. One patient could not be treated in the office due to limited endoscopic access. TNSS was reduced significantly after30 and 90 days (mean ± SD: 6.0 ± 0.7 prior to ablation, 2.3 ± 0.4 at 90 days, p < .001). Rhinitis and congestion scores decreased at 30 and 90 days after treatment compared to the baseline (p < .001). CONCLUSION: ELA of the PNN region is safe and well tolerated both in the office and ambulatory settings. Symptom scores were significantly decreased after 30 and 90 days. This new minimally invasive method appears to be a promising treatment method.

The effects of resection of the peripheral branches of the posterior nasal nerves in the inferior turbinate, with special focus on olfactory dysfunction.

OBJECTIVE: There are few detailed studies about peripheral branch resection of the posterior nasal nerves in the inferior turbinate; thus, this study aimed to investigate this. METHODS: Patients who underwent submucosal turbinoplasty with or without resection of the peripheral branches of posterior nasal nerves in the inferior turbinate were included. RESULTS: The resection of the posterior nasal nerves with turbinoplasty significantly reduced detection and recognition thresholds on olfactory testing. The rhinorrhoea severity, detection threshold and recognition threshold were significantly lower after resection of the posterior nasal nerves with turbinoplasty than after turbinoplasty alone, although there were no significant differences between the two groups before surgery. CONCLUSION: This is the first study to show that the resection of the peripheral branches of the posterior nasal nerves in the inferior turbinate with turbinoplasty more effectively inhibits allergic symptoms compared with turbinoplasty alone. It also showed that the resection of the peripheral branches of the posterior nasal nerves can inhibit olfactory dysfunction.

The inferior turbinate: An autonomic organ.

The inferior turbinate has well-recognized respiratory and immune functions to provide the airway with appropriate warmth, humidification, and filtration of the inspired air while sampling the environment for pathogens. Normal functioning of the inferior turbinate relies on an intact autonomic system to maintain homeostasis within the nasal cavity. The autonomic nervous system innervates the submucosal glands and the vasculature within the inferior turbinate, resulting in control of major turbinate functions: nasal secretions, nasal patency, warmth, and humidification. This review will summarize the autonomic innervations of the turbinates, both the normal and abnormal autonomic processes that contribute to the turbinate functions, and the clinical considerations regarding optimal functioning of the turbinate autonomic system.

Innervation of the Human Cavum Conchae and Auditory Canal: Anatomical Basis for Transcutaneous Auricular Nerve Stimulation.

The innocuous transcutaneous stimulation of nerves supplying the outer ear has been demonstrated to be as effective as the invasive direct stimulation of the vagus nerve for the treatment of some neurological and nonneurological disturbances. Thus, the precise knowledge of external ear innervation is of maximal interest for the design of transcutaneous auricular nerve stimulation devices. We analyzed eleven outer ears, and the innervation was assessed by Masson's trichrome staining, immunohistochemistry, or immunofluorescence (neurofilaments, S100 protein, and myelin-basic protein). In both the cavum conchae and the auditory canal, nerve profiles were identified between the cartilage and the skin and out of the cartilage. The density of nerves and of myelinated nerve fibers was higher out of the cartilage and in the auditory canal with respect to the cavum conchae. Moreover, the nerves were more numerous in the superior and posterior-inferior than in the anterior-inferior segments of the auditory canal. The present study established a precise nerve map of the human cavum conchae and the cartilaginous segment of the auditory canal demonstrating regional differences in the pattern of innervation of the human outer ear. These results may provide additional neuroanatomical basis for the accurate design of auricular transcutaneous nerve stimulation devices.

Endoscopic microdebrider-assisted inferior turbinoplasty with and without posterior nasal neurectomy.

OBJECTIVE: Endoscopic microdebrider-assisted inferior turbinoplasty (EMAIT) has been recognized as an efficient surgical technique in the management of hypertrophied inferior turbinate. In an attempt to further increase surgical successful outcomes, posterior nasal neurectomy (PNN) was developed. The aim of this retrospective case-control study was to assess the position of PNN in the surgery of hypertrophied turbinate. METHODS: Seventy patients were assigned to the two treatment groups: Group A (EMAIT) and Group B (EMAIT and PNN). Subjective outcomes were represented by symptom score and quality of life scores (Rhinoconjunctivitis Quality of Life Questionnaire - RQLQ). Objective outcomes were nasal resistance, saccharin transit time and acoustic rhinometry parameters. RESULTS: The survey demonstrated that symptoms and objective parameters improved postoperatively in both groups, with no statistical significant differences in objective and subjective outcomes between the surgical groups. CONCLUSION: The addition of PNN appears to offer no additional benefit in the subjective and objective outcome related with surgery of hypertrophied inferior turbinate. However, longer follow-up studies and larger number of patients are required in order to validate our results.

Nasal tactile sensitivity in allergic rhinitis.

CONCLUSION: These preliminary data show a decrease in nasal tactile sensitivity and point out interesting aspects of the nasal chronic inflammatory condition in allergic rhinitis. OBJECTIVES: The aim of this study was to evaluate the effects of allergic rhinitis on nasal tactile sensitivity during the intercritical period. METHODS: A total of 70 patients aged between 18 and 67 years (average 42 years), with a positive history of allergy caused by seasonal outdoor allergens, were included (group A). Patient outcome was assessed by the nasal monofilament test: a set of 20 Semmes-Weinstein monofilaments was used to detect nasal sensitivity for both nasal cavities. The sensitivity threshold was recorded as the minimum monofilament size with which patients could detect at least two of three stimuli. RESULTS: When compared to the control group (group B), subjects in group A required a significantly (p < 0.05) higher stimulus to trigger a touch response in the monofilament test, for both the inferior (195.1 ± 0.39 mg vs 67.7 ± 0.19 mg) and middle turbinate (108.7 ± 0.23 mg vs 67.7 ± 0.19 mg).

Evaluation of the feasibility of the vidian neurectomy using computed tomography.

For around 50 years, various approaches to the vidian neurectomy have been advocated. This indicates that there is no single surgical technique that is superior to all others. In this report, we analyze the included angle between the posterior end of middle turbinate and the anterior opening of the vidian canal. The aim of this paper is to use preoperative CT scanning to find a key anatomical structure to predict the feasibility of the vidian neurectomy. A retrospective research was performed. A total of 63 patients with 106 endoscopic vidian neurectomies between September 2006 and April 2010 were selected. The study population included 50 men and 13 women, with a mean age of 28. A paranasal sinus CT scan was obtained and analyzed. The included angle was measured and compared to the operating success rates. In the successful group (78 sides, 73.58%), the included angle from axial and coronal CT imaging was 30.2 ± 4.9° and 26.4 ± 9.1°, respectively. In the 28 failed sides (26.42%), the value was 33.8 ± 4.8° and 44.3 ± 8.1°, respectively. Statistical analysis confirmed that the difference between those two groups was significant (P < 0.05). The present study reports the relationship between the vidian canal and the middle turbinate, which is represented by their included angle. The findings support the decision to intervene the surgical side with a smaller angle, because of the significantly higher success rate.

Nasal tactile sensitivity in elderly.

CONCLUSION: Although older people varied widely in tactile sensitivity, our results show that tactile thresholds increased with age. OBJECTIVES: The aim of this study was to evaluate the effects of aging on nasal tactile sensitivity. METHODS: A total of 160 healthy patients aged between 50 and 90 years were included. According to their age, patients were divided into groups (A, B, C, D, E, F, G, and H). From the age of 50, each group included subjects with an age range of 5 years (i.e. group A, 50-55 years; group B, 56-60 years, etc.). Each patient's outcome was assessed through the nasal monofilament test: a set of 20 Semmes-Weinstein monofilaments was used to detect nasal sensitivity for both nasal cavities. The sensitivity threshold was recorded as the minimum monofilament size from which patients could detect at least two of three stimuli. RESULTS: In groups D (66-70 years), E (71-75 years), F (76-80 years), G (81-85 years), and H (86-90 years) a significantly (p < 0.05) higher stimulus (171.1 ± 0.34 mg vs 67.7 mg, 167.01 ± 0.31 mg 67.7 mg, 166.54 ± 0.28 mg 67.7 mg, 201.24 ± 0.43 mg 67.7 mg, 165,87 ± 0.27 mg 67.7 mg) was required to trigger a touch response in the monofilament test.

Effect of resection of the posterior nasal nerve on functional and morphological changes in the inferior turbinate mucosa.

CONCLUSIONS: The underlying pathophysiological mechanisms of the posterior nasal nerve (PNN) resection involved the suppression of the secretogogue motor and the inhibition of neurogenic inflammation induced by parasympathetic and sensory denervation. OBJECTIVE: The study was designed to clarify the underlying mechanisms of the resection of the PNN. PATIENTS AND METHODS: Ten patients with allergic rhinitis and non-allergic chronic rhinitis were enrolled in the study. Clinical symptoms were evaluated before and after administration of oxitropium bromide aerosol, and after the PNN resection. Biopsy specimens from the inferior turbinate mucosa obtained from five patients before and after resection of the PNN were examined. RESULTS: The application of oxitropium bromide resulted in a significant reduction of both watery rhinorrhea and nasal obstruction, but not sneezing or postnasal drip. Resection of the PNN also significantly improved both rhinorrhea and nasal obstruction. Morphometric analysis of the density of the nasal gland showed a significant reduction, whereas no significant change was recognized in the density of the vessels. A significant reduction in the number of infiltrating neutrophils, eosinophils, and lymphocytes was recognized.

Responses to trigeminal irritants at different locations of the human nasal mucosa.

BACKGROUND: Previous work suggests differences in the distribution of human intranasal trigeminal receptors. The aim of this study was to investigate these topographic differences for different concentrations of different trigeminal irritants using an electrophysiologic measure of trigeminal activation, the negative mucosa potential (NMP). MATERIALS AND METHODS: A total of 15 healthy volunteers participated. Presented by a computer-controlled olfactometer CO2 (30% and 40% v/v), ethyl acetate (5.5% and 9.3% v/v) and acetic acid (205 and 40% v/v) were used for stimulation. NMP was recorded at the middle septum, the middle turbinate, and the floor of the nasal cavity. RESULTS: Maximum amplitudes of the NMP were found at the middle septum and were lowest at the nasal floor. Response amplitudes were related to stimulus concentrations. There was no significant difference between responses to the three different stimuli in relation to three recording sites. CONCLUSIONS: In agreement with previous work, the present data suggest that there are topographic differences in the responsiveness of the mucosa to chemical irritants.

Recordings of the optical intrinsic signal from the middle turbinate in response to olfactory and trigeminal stimulation: a pilot study.

Responses from the middle turbinate elicited by olfactory and trigeminal stimuli were studied using the intrinsic optical signal (IOS) recording technique. Nasal cavity was illuminated by 617 nm light. Olfactory (H2S) or trigeminal (CO2) stimuli of 5-s duration were presented using a computer-controlled olfactometer; IOS responses were captured by a special camera. Averages across five individual IOS recordings were analyzed. When the nasal cavity was exposed to H2S, a significant change of the IOS was found; responses to CO2 were even more pronounced. The present results argue for the idea that the IOS is an indicator of intranasal chemosensory activation.

Submucous turbinectomy combined with posterior nasal neurectomy in the management of severe allergic rhinitis: clinical outcomes and local cytokine changes.

OBJECTIVES: Submucous resection of the inferior turbinate is one of the recommended methods to alleviate nasal symptoms in patients with severe allergic rhinitis patients in terms of postoperative results and preservation of nasal function. Posterior nasal neurectomy, recently developed by Kikawada, is a novel method to selectively cut the neural bundles out from the sphenopalatine foramen and to diminish the complaints of hypersecretion. This study was carried to examine the clinical effectiveness and changes in local cytokine levels of this combined surgical procedure. METHODS: Twenty-three patients with severe perennial allergic rhinitis underwent submucous turbinectomy combined with posterior nasal neurectomy under general anesthesia. The patients' subjective nasal symptoms were examined at each visit. The levels of interleukin-5 (IL-5), eotaxin and regulated on activation, normal T cell expressed and secreted (RANTES) in nasal lavages were measured before and 6 month after surgery. Nasal mucosa of the inferior turbinate was also obtained for histopathological examination in some cases. RESULTS: The mean symptom scores for sneeze, rhinorrhea, nasal obstruction, and total severity were all statistically decreased after surgery. Therapeutic effects continued to be apparent as long as 3 years after surgery. The mean levels of both IL-5 and eotaxin significantly decreased after surgery, but that of RANTES remained unchanged. Histopathological examination revealed that the number of inflammatory cells and nasal glands markedly reduced in lamina propria and the epithelial layer became covered with stratified columnar cells. CONCLUSION: Submucosal turbinectomy with posterior nasal neurectomy has remarkably improved subjective nasal symptoms in patients with severe allergic rhinitis on a long-term follow-up basis. The present study also demonstrates that the clinical effectiveness of the procedure is accompanied by decreases in local inflammatory cell infiltration and the related cytokine production.

[The distribution of nerves in inferior turbinate].

OBJECTIVE: The distribution of nerve in inferior turbinate was observed to provide anatomy evidence for inferior turbinate surgery by measuring and dissecting corpses. METHOD: Inferior turbinate was dissected under the microscope in 20 heads of corpses. RESULT: (1) The posterior inferior nasal nerve marched down between the mucosa and the periosteum, and entered the inferior turbinate at the site 6 to approximately 13 mm before the end of inferior turbinate. (2) The antierethmoid nerve went to the inferior turbinate 2.0 to approximately 4.6 mm behind the beginning of the inferior turbinate. CONCLUSION: Selective cut of the nerves of the inferior turbinate under the nasal endoscope is feasible.

[NPY in human nasal mucosa -- an immunocytochemical and immunoelectron microscopical study]. / Neuropeptid Y in der Nasenschleimhaut des Menschen -- eine immunhistochemische und immunelektronenmikroskopische Untersuchung.

BACKGROUND: The functions of the nasal mucosa are regulated by numerous endogenous and exogenous influences. The innervation patterns are important for the control of the physiological nasal functions. In addition to the classic neurotransmitters different neuropeptides might play a regulating and modulating role in the nasal mucosa. Both the significance and the localization of neuropeptide Y (NPY) have not been fully elucidated. PATIENTS AND METHODS: Tissue samples of human inferior turbinates from 42 patients were taken during nasal surgery and preserved in phosphate-buffered paraformaldehyde or glutaraldehyde. Serial sections were incubated with antibodies against NPY and the ABC method was applied. In order to identify immunoelectron microscopic reactions a streptavidin-gold-marker was used. The findings were photodocumented by using a light- and transmission-electron microscope. RESULTS: NPY-positive terminals were mainly located in the adventitia of arterial vessels. There were also NPY-immunoreactive arterioles near to the glands. Periglandular a lower density of immunoreactions could be observed. NPY-positive fibers could be detected in the subepithelial connective tissue and at the glandular ducts. Immunoelectron microscopy revealed NPY within periglandular axons. CONCLUSIONS: Immunohistochemical and immunoelectron microscopical methods allow a detailed identification of the sympathetic cotransmitter NPY in arterial vessels of nasal mucosa in man. These results indicate that NPY-containing nerve fibers innervate arteries as well as nasal glands. These findings suggest that NPY play a significant role as a neuromodulator in the control of both vasculature and glandular secretion. The localisation of NPY in periglandular and periductal nerves confirms the direct influence of glandular functions. NPY-agonists may be a beneficial additional treatment of rhinopathies to reduce nasal obstruction and mucus secretion.

Olfaction preservation in anterior cranial base approaches: an anatomic study.

OBJECTIVE: To study the anatomic basis for olfaction-sparing anterior cranial base approaches. METHODS: The medial anterior skull base containing the olfactory unit and delimited by the inner table of the frontal sinus, the lesser wing of the sphenoid bone, and the medial orbital walls was removed from six cadaveric specimens. Histological methods were used to investigate the location, distribution, and depth of penetration of olfactory nerves. Hematoxylin and eosin and Gomori trichrome staining were used to visualize landmarks and architecture. S-100 neurofilament protein immunostaining was used to identify nerve fascicles and axons. In three cadaveric head specimens, olfaction-sparing craniofacial approaches were performed and the excised olfactory units were evaluated histologically. RESULTS: Bundles of olfactory nerves were identified primarily in the nasal septum; relatively fewer bundles could be identified in the middle turbinate. Olfactory nerve endings were identified up to 20 mm below the cribriform plate (range, 7-20 mm). The superior and middle nasal meatus were most innervated; olfactory innervation was virtually absent in the inferior nasal meatus. Histological evaluation of the olfactory unit elevated during olfaction-sparing techniques routinely revealed transection of olfactory nerves that exited the skull base. CONCLUSION: In olfaction-sparing anterior cranial base approaches, the olfactory nerves are inevitably transected. The clinical significance of olfactory nerve transection for postoperative functional recovery of olfaction remains to be analyzed.

Intranasal lidocaine to prevent headache following migraine aura.

OBJECTIVE: To report the consistent effect of intranasal lidocaine 4% on preventing headache following aura in one individual. BACKGROUND: A treatment that could prevent the headache which follows an aura would be an important advance in the treatment of migraine. No migraine abortive treatment has been shown to have such an effect. METHODS: A 15-year-old adolescent boy with a history of recurrent headache since aged 2, fulfilling the criteria for migraine with aura, was seen in consultation. Intranasal lidocaine 4% was used during the aura phase to prevent the headaches. RESULTS: Before using intranasal lidocaine, the patient invariably experienced a migraine following a typical visual aura. The episodes occurred approximately weekly, with a stable pattern for several years. When given during the aura, intranasal lidocaine prevented the headache following the aura, and remained successful on all but two occasions over 1 1/2 years of use (approximately 75 episodes). There was no effect on the duration of the aura itself. CONCLUSIONS: Intranasal lidocaine consistently prevented the development of headache symptoms following aura in this individual. Such an effect suggests a role for the sphenopalatine ganglion in the development of migraine pain.

[Endogenously formed nitric oxide in nasal mucosa of the human: detection by nicotinamide-adenine dinucleotide phosphate diaphorase (NADPH-d) histochemistry]. / Endogen gebildetes Stickstoffmonoxyd in der Nasenschleimhaut des Menschen: Nachweis mittels Nikotinamid Adenin Dinukleotid Phosphat-Diaphorase (NADPH-d) Histochemie.

BACKGROUND: Nitric oxide (NO) is an intercellular transmitter, both in the central and in the peripheral nervous system. In addition to nerve cells, NO is also produced in epithelial cells of various tissues and in the endothelium. NO is formed by the action of nitric oxide synthase (NOS). There is evidence that NOS can be marked by NADPH-diaphorase (NADPH-d) activity in many cell types. The aim of this study was to identify NOS-positive structures in human nasal mucosa by using NADPH-d-histochemistry. METHODS: Frozen sections from inferior turbinates were fixed with buffered formalin and then treated according to the description of Vincent and Kimura. Additionally, the same sections underwent a double staining procedure for acetylcholinesterase (Karnovski-Roots) to show a correlation with cholinergic nerve structures. RESULTS: Strong reactions were found in the epithelium and in nerve fibres, compared to less NADPH-d activity in seromucous glands and the endothelium of the different vessel types. Singular NADPH-d positive nerves were found within nerve bundles, periarterially, in the subepithelial layer and surrounding glands and their ducts. A frequent localisation of NADPH-d could be detected in parasympathetic nerve fibres. CONCLUSIONS: The occurrence of NADPH-d in epithelial, glandular and nerval structures suggests that NOS takes part in physiological functions and possible pathophysiological processes of the nose. Similar to findings in various other organs this investigation demonstrated that the neurotransmitter NO can also be associated with the parasympathetic nervous system in the human nasal mucosa.

[Current immunohistochemical results of localization of vasoactive intestinal polypeptide (VIP) in nasal mucosa of the human]. / Aktuelle immunhistochemische Ergebnisse zur Lokalisation von vasoaktiv intestinalem Polypeptid (VIP) in der Nasenschleimhaut des Menschen.

Besides classic neurotransmitters, neuropeptides seem to participate in the control of human nasal physiology. In this region vasoactive intestinal peptide (VIP) is found in higher concentration than other neuropeptides. The aim of this study was to localize VIP in neuronal and non-neuronal structures of the human nasal mucosa using immunocytochemical techniques. Paraffin and frozen serial sections of the inferior turbinate were incubated with antibodies against neuronspecific enolase (NSE) to demonstrate neuronal structures or against VIP. The immunocomplexes were visualized by the Avidin-Biotin-Complex (ABC)-method. VIP-positive nerve fibers were found around the acinus cells and the ducts of the seromucous glands. These results emphasize the influence of VIP on nasal gland secretion. Few immunoreactions to the VIP were demonstrated in the nerves of the adventitia of veins and arteries. Additionally, by comparing NSE nad VIP localization, strong extranerval immunoreactions in the tunica medica of the arterioles were demonstrated, as were lesser but still visible immunoreactions in the muscular layer of thick veins. These morphological findings in vessels and the well known vasodilatory effect of VIP underline the functions of this neuropeptide on the nasal mucosa in man. Thus, by increasing the blood flow and volume, VIP, in conjunction with other control factors, seems to participate in the physiological processes of the swelling mechanism of nasal turbinates and influence nasal congestion.

[Immunohistochemical studies of the neuroanatomy of the human turbinates: innervation pattern of seromucous glands]. / Immunhistochemische Untersuchungen zur Neuroanatomie der menschlichen Nasenmuschel: Innervationsmuster der seromukösen Drüsen.

Seromucous glands are among the main components of human nasal mucosa. To control the different physiological functions of these glands, a dense nerval network is necessary. The aim of this study was to demonstrate the general innervation of the seromucous glands in nasal mucosa. Tissue samples of inferior human turbinates were fixed and embedded in paraffin wax or frozen. Serial sections were performed and incubated with antibodies either to neuron-specific enolase (NSE) or S-100 protein. The ABC method was employed to demonstrate the immunacomplexes. The sections were counterstained with haemotoxylin. Either NSE and S-100 protein-immunoreactive nerve fibres were found around the acini, ducts and in the connective tissue of the glands. Furthermore, a dense network of fine nerve fibres was detected in the submucosal region. The localisation of neurons in nasal glands confirms the direct nerval control of the diverse glandular functions. Additionally, the sensitive subepithelial network of fine nerve fibres might be involved in the regulation of glandular secretion.

Human olfactory neurons respond to odor stimuli with an increase in cytoplasmic Ca2+.

The sense of smell allows terrestrial animals to collect information about the chemical nature of their environment through the detection of airborne molecules. In humans smell is believed to play an important role in protecting the organism from environmental hazards such as fire, gas leaks and spoiled food, in determining the flavor of foods, and perhaps in infant-parent bonding. In addition, the study of human olfaction is relevant to a number of medical problems that result in olfactory dysfunction, which can affect nutritional state, and to the study of the etiology of neurodegenerative diseases which manifest themselves in the olfactory epithelium. Although much is known about behavioral aspects of human olfaction, little is understood about the underlying cellular mechanisms in humans. Here we report that viable human olfactory neurons (HON) can be isolated from olfactory tissue biopsies, and we find that HON respond to odorants with an increase in intracellular calcium concentration ([Cai]).