Kulak Burun Bogaz Ihtis Derg
2005;14(5-6):110-115
ORIGINAL ARTICLE
Radiofrequency for the treatment of vasomotor rhinitis
Vazomotor rinit tedavisi için radyofrekans uygulamas›
Fuat TOSUN, M.D.,1 Zafer ÇALIfiKANER, M.D.,2 Abdullah DURMAZ, M.D.,1
Mustafa GEREK, M.D.,1 Yalç›n ÖZKAPTAN, M.D.1
Objectives: We assessed the efficacy of submucosal application of radiofrequency to the inferior
turbinate for the treatment of vasomotor rhinitis.
Patients and Methods: Twenty patients with vasomotor rhinitis (9 males, 11 females; mean age 29.2
years; range 20 to 40 years) were treated with
radiofrequency applied to the inferior turbinate.
Symptoms such as nasal obstruction, sneezing, and
watery nasal discharge were graded with the use of
a visual analog scale (VAS) before, and on days 1,
3, 7, 30, 60, 90, and 180 after the treatment.
Results: The severity of symptoms began to
decrease following the first week after the application.
Maximum relief was achieved between 30 to 60 days
after the intervention. The highest rate of improvement
(85.4%) was reported in sneezing, followed by nasal
obstruction (76.4%) and nasal discharge (67.7%). The
mean VAS scores showed a significant improvement
in all symptoms between 7 to 180 days after the procedure (p<0.05). The rate of patient satisfaction was
90% for the relief of nasal obstruction and sneezing,
and 80% for nasal discharge. Complaints about vasomotor rhinitis increased up to a severity near the pretreatment level in eight patients on the 180th postoperative day and the procedure was repeated.
Conclusion: These findings indicate that radiofrequency may be used as an alternative treatment
option in patients with vasomotor rhinitis.
Amaç: Bu çal›flmada inferior konkaya submukozal
radyofrekans uygulamas›n›n vazomotor rinit tedavisindeki etkinli¤i araflt›r›ld›.
Hastalar ve Yöntemler: Çal›flmaya vazomotor rinitli 20 hasta (9 erkek, 11 kad›n; ort. yafl 29.2; da¤›l›m
20-40) al›nd›. Tüm hastalar inferior konkaya radyofrekans uygulamas›yla tedavi edildi. Hastalar›n burun t›kan›kl›¤›, hapfl›rma ve sulu burun ak›nt›s› flikayetleri tedaviden önce ve ifllem sonras› 1, 3, 7, 30,
60, 90 ve 180. günlerde görsel analog skala ile de¤erlendirildi.
Bulgular: Tüm hastalarda semptomlar›n ciddiyeti
radyofrekans uygulamas›ndan bir hafta sonra azalmaya bafllad›. En fazla iyileflmenin ifllemden 30 ile
60 gün sonra elde edildi¤i görüldü. En yüksek iyileflme oran› hapfl›rmada (%85.4) elde edilirken, bunu
burun t›kan›kl›¤› (%76.4) ve burun ak›nt›s›ndaki
(%67.7) iyileflme izledi. Tedaviden sonra yedi ile
180. günler aras›nda bütün semptomlardaki iyileflme
derecesi anlaml›yd› (p<0.05). Hastalar›n %90’› burun t›kan›kl›¤› ve hapfl›rmadaki düzelmeden, %80’i
burun ak›nt›s›ndaki iyileflmeden memnundu. Ameliyat sonras› 180. günde sekiz hastada vazomotor rinite ba¤l› yak›nmalar tedavi öncesi düzeye yükseldi
ve ifllem tekrarland›.
Sonuç: Bu bulgular radyofrekans uygulamas›n›n vazomotor rinitli hastalarda bir tedavi yöntemi olarak
kullan›labilece¤ini gösterdi.
Key Words: Catheter ablation; nasal mucosa/ surgery; nasal
obstruction/pathology; patient satisfaction; rhinitis, vasomotor/therapy; turbinates/surgery.
Anahtar Sözcükler: Kateter ablasyonu; burun mukozas›/
cerrahi; burun t›kan›kl›¤›/patoloji; hasta memnuniyeti; rinit,
vazomotor/tedavi; turbinat/cerrahi.
◆
Departments of 1Otolaryngology and 2Allergic Diseases, Gülhane Military Medical School (Gülhane Askeri T›p Akademisi, 1Kulak Burun Bo¤az
Hastal›klar› Anabilim Dal›, 2Alerjik Hastal›klar Anabilim Dal›) Ankara, Turkey.
◆
Received - May 7, 2004 (Dergiye gelifl tarihi - 7 May›s 2004). Request for revision - September 2, 2004 (Düzeltme iste¤i - 2 Eylül 2004).
Accepted for publication - October 11, 2004 (Yay›n için kabul tarihi - 11 Ekim 2004).
◆
Correspondence (‹letiflim adresi): Dr. Fuat Tosun. Gülhane Askeri T›p Akademisi KBB Hastal›klar› Anabilim Dal›, 06018 Etlik, Ankara, Turkey.
Tel: +90 312 - 304 57 01 Fax (Faks): +90 312 - 304 57 00 e-mail (e-posta): fuattosun@yahoo.com
110
Radiofrequency for the treatment of vasomotor rhinitis
Vasomotor rhinitis is a noninfectious chronic
rhinopathy, which has most of the symptoms of
allergic rhinitis without an allergic basis. These
patients mainly complain of nasal blockage, nasal
secretion and less frequently sneezing.[1,2]
Medications, which give good results in allergic
rhinitis, may have a poor benefit in vasomotor
rhinitis.[3] Many other treatment modalities including local application of silver nitrate and botulinum
toxin, vidian neurectomy, laser cautery, submucosal diathermy and cryotherapy have also been used
for the treatment of patients with vasomotor rhinitis.[4-8] All of these treatment methods have their
own drawbacks like the eye dryness of vidian
neurectomy, increased postoperative pain and prolonged healing period after cryotherapy,
osteonecrosis of the turbinate bone after submucosal diathermy, and anosmia after application of silver nitrate.[6-9] In recent years successful treatment
of these patients by local application of capsaicin
was reported but it causes local irritation and
severe nose burning during the procedure.[10]
School. All patients had a history of different degree
of nasal discharge, nasal obstruction and sneezing,
which were reported to be refractory, or got only a
poor relief from topical steroid. Examination
included anterior rhinoscopy and nasal endoscopy
in all patients to evaluate colour of mucosa,
swelling of turbinates, features of secretion,
anatomical variations and any other pathologic
changes of the nasal passages. Paranasal sinuses
were evaluated with computerized tomography,
which was taken on the coronal plane.
Nasal smear and skin prick test (SPT) were performed at the Department of Allergic Diseases. SPT
was carried out by using 55 common aeroallergens
(pollens commonly found in atmosphere, molds,
house dust mites and animal dander (Greer Lab,
Lenoir, USA). Saline solution was used for negative
controls and histamine was used for positive controls. SPT was performed with disposable lancets
and the diameter of the erythema and the wheal
were recorded at 15 minutes. Reactions with a wheal
diameter larger than or equal to 3 mm were considered to be positive. Intradermal tests were also performed in patients whose preceding SPT was negative. Grass, weed and tree pollen and house dust
mites extracts were used (Greer Lab, Lenoir USA). A
wheal and flare reaction larger than negative control
was accepted positive. Patients with symptoms and
findings of vasomotor rhinitis who had no
eosinophils on nasal smear and showed a negative
SPT and a negative intradermal test were included
in the group of vasomotor rhinitis.
Recently RF has successfully been used for inferior turbinate hypertrophy.[11-14] No complication was
reported by the authors except mild to moderate pain
in some of the patients during the procedure and
transient nasal obstruction due to edema of the
turbinate after RF application.[11-13] No crusting, bleeding or synechia of the turbinate has been reported
because RF energy had been delivered submucosally.
The mucosa of the turbinate remains healthy to maintain normal function after the procedure.[15]
Patients who had previous nasal surgery, had
findings of sinusitis on physical examination or on
computerized tomography, had any kind of rhinitis
(drug induced, endocrine, infectious) except vasomotor rhinitis, had nasal polyps or anatomical variations of the nasal structures and had a history of
using topical steroid in the last one month were
excluded from the study.
Previous studies with RF application in rhinology have mainly focused on nasal obstruction due to
inferior turbinate hypertrophy in any origin. In this
study we aimed to evaluate the efficacy of submucosal application of RF on symptoms of vasomotor
rhinitis, including nasal discharge and sneezing in
addition to nasal obstruction.
PATIENTS AND METHODS
Each patient used a 10 cm visual analog scale to
grade symptoms. A score of “0” indicated very little
or no symptoms, while a score of “10” represent the
most severe degree of symptoms. Patients filled the
VAS for nasal obstruction, sneezing and nasal discharge preoperatively and on days 1, 3, 7, 30, 60, 90,
and 180 after the procedure. Examination of nasal
passage and inferior turbinates were also performed
on the same dates.
Twenty patients with vasomotor rhinitis, 9 men
and 11 women with a range of ages, between 20 to
40 years (mean 29.2 years) were included in the
study. Ten of these patients were included into control group during the first two months. A written
informed consent form was taken before being
included in the study, which was approved by the
ethical committee of Gülhane Military Medical
111
Radiofrequency for the treatment of vasomotor rhinitis
three days after the RF procedure (9.64±0.1, 9.35±0.1
and 8.71±0.5 for nasal obstruction, sneezing and
nasal discharge respectively). Symptomatic relief
began after the first week with mean scores
5.00±0.3, 5.40±0.3 and 5.21 ±0.4 for nasal obstruction, sneezing and nasal discharge respectively
(Table I). Degree of improvement at the end of first
postoperative week was statistically significant as
compared with preoperatively (p<0.05).
Procedure
All procedures were performed with the patients
under local anaesthesia. Cotton pledges, soaked with
2% pantocaine were placed into the nasal passage for
10 minutes. Then the pledges were removed and
inferior turbinates were injected with 1% lidocaine.
Ellman Surgitron EMC unit, which had an output 3.8
MHz, was used as radiofrequency generator. RF was
delivered into the inferior turbinates on coagulation
mode (partially rectified waves) by using bayonet
type 45-mm long bipolar turbinate probe. The probes
were placed in the anterior portion of the inferior
turbinate and deeply inserted along the medial face
of the turbinate bone. A power of 30 watts was used
to deliver radio wave emissions into the turbinate for
20 seconds. The same procedure was performed in
the lower, middle and upper portion of the inferior
turbinates. Nasal packing was not used after the procedure. Paracetamol was used for pain control. Thick
mucus that accumulated in the nasal passage was
removed by aspiration during the first week after the
procedure. The same procedure was performed in
the control group without delivering radiofrequency
at first. This group underwent a second procedure to
apply radiofrequency as in the other patients at the
end of 2 months follow-up period. They were also
subjected to the same follow-up procedure as in the
treatment group after this period.
Symptomatic improvement reached maximum
between days 30 and 60 after the intervention (Fig. 1).
Mean symptom scores, reported by patients on 30th
postoperative day were 2.07±0.2 for nasal obstruction, 1.19±0.2 for sneezing and 3.28±0.3 for nasal discharge. The highest rate of improvement was reported in sneezing (85.38%) and the lowest rate of relief
was in nasal discharge (61.72%) on 30 Th postoperative day (Table I). Mean symptom scores, reported on
60th postoperative day were 2.71±0.4, 1.80±0.3, and
3.71±0.3 for nasal obstruction, sneezing and nasal discharge respectively. Rate of improvement, reported
on days 30 and 60 after the RF procedure was statistically significant as compared with preoperatively
(p<0.05). On the other hand when patients’ symptoms evaluated one by one 16 (80%) of the 20 patients
reported that improvement rate of nasal discharge
between 30 to 90 days postoperatively was satisfactory. Patients’ satisfaction was 90% (18 of 20 patients)
with the improvement rate of nasal obstruction and
sneezing in this period.
Paired Student t test was used for statistical
analysis and a p value of less than 0.05 was considered to be statistically significant.
Symptomatic relief was seen to be decreased on
postoperative 90th day but rate of improvement was
still statistically significant (p<0.05). Reported mean
symptom scores were changed as 4.14±0.3, 3.50±0.5
and 5.14±0.5 for nasal obstruction, sneezing and
nasal discharge respectively. Although symptom
scores of vasomotor rhinitis were continued to
increase slowly in sixth month postoperatively
(4.71±0.4, 4.57±0.4 and 5.42±0.5 for nasal obstruction, sneezing and nasal discharge respectively), the
difference between mean symptom scores as compared with preoperatively was still statistically significant (p<0.05). However complaints of patients
increased up to a level near the preoperative degree
in 8 patients and the procedure was repeated. Other
12 patients reported that they were still satisfied
with their symptomatic relief.
RESULTS
All of the 20 patients had different degree of
symptoms of vasomotor rhinitis preoperatively.
Preoperative mean symptom scores did not change
significantly in the control patients (8.54±0.1,
8.03±0.2 and 8.46±0.6 respectively for mean degree
of nasal obstruction, sneezing and nasal discharge
preoperatively and 8.51±0.2, 8.04±0.1, 8.44±0.6
respectively for the same symptoms between 30 to
60 days postoperatively) at the end of second postoperative month (p>0.05). These patients underwent a second procedure to apply radiofrequency
after this period and were included in the treatment
group. Mean degree of nasal obstruction, sneezing
and nasal discharge, scored by all the patients preoperatively were 8.64±0.1, 8.14±0.2 and 8.57±0.6
respectively. Symptoms increased during the first
Anterior rhinoscopy and nasal endoscopy
revealed involution of inferior turbinate, continuing
112
Radiofrequency for the treatment of vasomotor rhinitis
TABLE I
MEAN SYMPTOM SCORES (SCORED BY USING VISUAL ANALOG SCALE) REPORTED BY 20 PATIENTS
PREOPERATIVELY AND ON DAYS 1, 3, 7, 30, 60, 90, AND 180 AFTER THE TREATMENT
Symptoms Mean scores, reported by the patients
preoperatively
day-1
day-3
day-7
day-30
day-60
day-90
day-180
Nasal obstruction
Improvement rate %
8.64±0.1
–
9.64±0.1
–
9.64±0.1
–
5.00±0.3
42.12
2.07±0.2
76.04
2.71±0.4
68.63
4.14±0.3
52.08
4.71±0.4
54.48
Sneezing
Improvement rate %
8.14±0.2
–
9.35±0.1
–
9.20±0.1
–
5.40±0.3
32.43
1.19±0.2
85.38
1.80±0.3
77.88
3.50±0.5
57.00
4.57±0.4
43.85
Nasal discharge %
Improvement rate
8.57±0.6
–
8.71±0.5
–
8.70±0.1
–
5.21±0.4
39.20
3.28±0.3
61.72
3.71±0.3
56.70
5.14±0.5
40.02
5.42±0.5
36.75
parallel with symptomatic course. Inferior
turbinates were pale and hypertrophic in all patients
preoperatively and were seen to be swollen during
first week after the intervention. Patients were called
to repeated examination and thick mucus, accumulated between turbinate and nasal septum was
removed in this period. Inferior turbinates were
reduced in volume during first and second month
after the treatment. Thick mucus was seen in the
control group after the early postoperative period
but the inferior turbinates did not reduce in volume
in these patients.
DISCUSSION
Vasomotor rhinitis is a nonspesific chronic
rhinopathy, which is accepted an exclusion of diagnosis.[16] Nasal smear for eosinophils and skin tests
for specific allergens are negative in these patients.
Mast cells have been found in nasal secretions of
patient with vasomotor rhinitis but the significance
of this finding is not clear. The mechanism is therefore nonallergic and most likely related to an abnormality of the autonomic nervous system. Over activity of parasympathetic innervation of nose, which is
triggered by exposure to non-specific environmental
factors such as sudden change in temperature or
humidity and by emotional factors, initiates symptoms of vasomotor rhinitis. Symptoms of these
patients are generally perennial and respond poorly
All patients tolerated the procedure well and
completed the study. Transient nasal obstruction in
the first week after the procedure was the only
minor complication, encountered.
Nasal obstruction
10.0
Sneezing
Nasal discharge
Symptom scores
7.5
5.0
2.5
0.0
Preop
Day 1
Day 3
Day 7
Day 30
Day 60
Day 90
Day 180
Follow-up
Fig. 1 - Course of mean symptom scores preoperatively and on days 1, 3, 7, 30, 60, 90, and 180 after the treatment in
20 patients.
113
Radiofrequency for the treatment of vasomotor rhinitis
to antiallergic medications including antihistamines,
decongestants, corticosteroids and cromolyn sodium.[17]
cant improvement of nasal obstruction, sneezing
and nasal discharge one year after the RF application to the turbinates in patients with allergic rhinitis. In our study improvement of symptoms (nasal
obstruction, sneezing and nasal discharge) began
after the first week postoperatively (p<0.05).
Maximum relief was detected between 30 and 60
days after the intervention. The best result was
detected in sneezing with 85.38 % of improvement
rate and the lowest improvement rate (61.72%) was
reported in nasal discharge on the postoperative
30th day after the intervention by the patients (Table
I). Ninety percent of the patients reported that the
improvement rates of nasal obstruction and sneezing were satisfactory between 30 to 90 days postoperatively. In the previous studies symptomatic
improvements were reported to be maintained during 1-year follow-up period.[14,15] In our study reported symptomatic relief was seen to be slowly
decreased between 60 to 180 days after the intervention (Fig. 1). By six months after the treatment there
was still a statistically significant difference between
mean sore of symptoms as compared with preoperatively (p<0.05). However 8 patients reported that
their complaints due to vasomotor rhinitis increased
up to uncomfortable level and the procedure was
repeated.
RF application into the inferior turbinate was
used for the treatment of vasomotor rhinitis in this
study. The mechanism of RF is based on the passage
of energy through an electrode to the surrounding
tissue in a radial fashion. The energy, coming from
the source spreads into the surrounding tissue from
the active electrode. Active electrode does not produce heat by itself. The current induces an ionic agitation in the tissue and this leads to protein friction
and heat liberation.[1] Heating leads to protein
denaturation when 49.5 °C is reached. The factors
that mainly affect degree of heating are current
intensity (in watts), time (in seconds), and electrode
size and length. An increase in any of these factors
will increase tissue heating.[18] High frequency radio
waves cause a coagulation necrosis in the submucosal tissue by heating. Consequently the circumscribed area of submucosal necrosis is replaced over
time by fibrotic tissue without any damage of
epithelial surface.[19]
Wound contraction due to fibrosis, results in volumetric reduction of the turbinate, leading to relief
of nasal obstruction in-patients with vasomotor
rhinitis. Submucosal fibrosis and obliteration of
venous sinusoids in these patients due to RF may
alter the response to various stimulants as described
in submucosal diathermy.[20] Submucosal heating
during RF may also cause degeneration of the C
fibers containing different neuropeptides, which are
assumed to play an important role in the mechanism
of aspecific nasal hyperreactivity. Inferior turbinate
is accepted to be an important trigger zone, of which
stimulation leads to sneezing and rhinorrhoea.[7] RF
relieves symptoms of vasomotor rhinitis by reducing response of the inferior turbinate to various
stimulations but further studies are needed to reveal
exact mechanism.
No significant complication was reported after
submucosal application of RF to the inferior
turbinates in the previous studies.[12,14,22,23] In a recent
study Sapci et al. reported obstruction was significantly improved after the radiofrequency tissue
ablation of the inferior turbinate with preserving
normal nasal mucociliary function.[24] In this study
postoperative nasal obstruction, which results from
swelling of the inferior turbinates and as a result of
accumulation of thick mucus in the nasal passage
were detected in all patients in the first postoperative week. Mild pain controlled with acetminophen
and accumulated mucus was removed by aspiration. Aggravation of sneezing and nasal discharge
that has been observed during the first three days
due to inflammation began to relieve after the postoperative first week. No other complication was
encountered.
Elwany et al.[15] used a RF unit with a bipolar
probe in patients with hypertrophied inferior
turbinates and 76% of the patients reported a significant improvement of their nasal obstruction one
year postoperatively. In the same study electron
microscopic examination of the nasal mucosa
revealed an intact healthy epithelium as well as
intense fibrosis of the underlying stroma at the end
of follow-up period.[15] Lin et al.[21] reported signifi-
In conclusion submucosal application of RF to
the inferior turbinates was seen to be a safe surgical
procedure, significantly reducing symptoms of
vasomotor rhinitis in most of the patients at least
114
Radiofrequency for the treatment of vasomotor rhinitis
12. Coste A, Yona L, Blumen M, Louis B, Zerah F, Rugina
M, et al. Radiofrequency is a safe and effective treatment of turbinate hypertrophy. Laryngoscope
2001;111:894-9.
13. Utley DS, Goode RL, Hakim I. Radiofrequency energy
tissue ablation for the treatment of nasal obstruction
secondary to turbinate hypertrophy. Laryngoscope
1999;109:683-6.
14. Smith TL, Correa AJ, Kuo T, Reinisch L.
Radiofrequency tissue ablation of the inferior
turbinates using a thermocouple feedback electrode.
Laryngoscope. 1999;109:1760-5.
15. Elwany S, Gaimaee R, Fattah HA. Radiofrequency
bipolar submucosal diathermy of the inferior
turbinates. Am J Rhinol 1999;13:145-9.
16. Jones AS, Lancer JM. Vasomotor rhinitis. Br Med J
(Clin Res Ed) 1987;294:1505-6.
17. McDonald TJ. Nasal disorders in children. Allergic
rhinitis, vasomotor rhinitis, and nasal polyps.
Postgrad Med 1987;81:65-8, 70, 72 passim.
18. Guilleminault C, Chervin R, Palombini L, Powell N.
Radiofrequency (pacing and thermic effects) in the
treatment of sleep-disordered breathing. Sleep 2000;23
Suppl 4:S182-6.
19. Courey MS, Fomin D, Smith T, Huang S, Sanders D,
Reinisch L. Histologic and physiologic effects of electrocautery, CO2 laser, and radiofrequency injury in the
porcine soft palate. Laryngoscope 1999;109:1316-9.
20. Jones AS, Wight RG, Kabil Y, Beckingham E.
Predicting the outcome of submucosal diathermy to
the inferior turbinates. Clin Otolaryngol 1989;14:41-4.
21. Lin HC, Lin PW, Su CY, Chang HW. Radiofrequency
for the treatment of allergic rhinitis refractory to medical therapy. Laryngoscope 2003;113:673-8.
22. Fischer Y, Gosepath J, Amedee RG, Mann WJ.
Radiofrequency volumetric tissue reduction (RFVTR)
of inferior turbinates: a new method in the treatment
of chronic nasal obstruction. Am J Rhinol 2000;14:35560.
23. Li KK, Powell NB, Riley RW, Troell RJ, Guilleminault
C. Radiofrequency volumetric tissue reduction for
treatment of turbinate hypertrophy: a pilot study.
Otolaryngol Head Neck Surg 1998;119:569-73.
24. Sapci T, Sahin B, Karavus A, Akbulut UG. Comparison
of the effects of radiofrequency tissue ablation, CO2
laser ablation, and partial turbinectomy applications
on nasal mucociliary functions. Laryngoscope
2003;113:514-9.
during the 3 months period. It is also an easy office
procedure that can be applied with minimal discomfort of the patients and without any pathologic
change of nasal mucosa. These findings indicate that
submucousal application of RF to the turbinates
may be used as an alternative treatment option in
patients with vasomotor rhinitis and is candidate
further clinical and laboratory investigations.
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