Minimally invasive selective posterior nasal neurectomy (PNN) has emerged as a targeted surgical option for patients with severe, treatment-refractory perennial allergic rhinitis. Allergic rhinitis is a highly prevalent condition and poses a significant burden on daily activities, quality of life, and academic or occupational performance, particularly among young adults [1]. Although medical therapy with intranasal corticosteroids, antihistamines, remains the cornerstone of management, a subset of patients continues to experience persistent nasal obstruction, rhinorrhoea, and sneezing despite optimal treatment, necessitating consideration of surgical interventions [1,3]. The pathophysiology of allergic rhinitis involves heightened parasympathetic activity and neural reflexes within the nasal mucosa that promote glandular hypersecretion and vasodilatation. Surgical interruption of these neural pathways has therefore been explored as a means of symptom control. Vidian neurectomy was historically employed for this purpose and proved effective, but its widespread use has been limited by adverse effects such as dry eye, palatal numbness, and other complications due to extensive denervation [2]. To overcome these limitations, attention has shifted toward more selective and minimally invasive techniques targeting the posterior nasal nerve branches while preserving surrounding neural structures [2, 4]. Endoscopic selective posterior nasal neurectomy allows precise interruption of parasympathetic fibers supplying the posterior nasal cavity, thereby reducing rhinorrhoea and nasal congestion with fewer postoperative complications. Clinical studies have demonstrated encouraging symptom relief and an improved safety profile, particularly when PNN is combined with inferior turbinate procedures in patients with perennial allergic or vasomotor rhinitis [4, 5]. Moreover, surgical modification of the inferior turbinate has been shown to complement neural procedures by improving airflow and reducing mucosal inflammation [3]. In this context, minimally invasive selective PNN represents a promising surgical alternative for patients with severe perennial allergic rhinitis unresponsive to medical therapy. The present study evaluates the effectiveness and benefits of this technique in alleviating symptoms and improving patient outcomes, thereby assessing its utility in contemporary management of refractory allergic rhinitis [2, 4, and 5].

Study design:. This was a questionnaire-based, retrospective follow-up study evaluating postoperative outcomes of minimally invasive selective posterior nasal neurectomy (PNN) in patients with severe perennial allergic rhinitis. Place of study: Department of Otorhinolaryngology, IPGME&R, Kolkata, West Bengal, India. Period of study: 01 July 2020 to 30 June 2025. Study Population and Sample size: A total of 62 patients (45 males, 17 females) underwent surgery during the study period. Patients who were operated on less than one year prior to the date of follow-up were excluded. Out of the 62 operated patients, 28 were lost to follow-up. The remaining 34 patients (24 males, 10 females) participated in the study and were included in the final analysis. Inclusion Criteria: • Patients with severe perennial allergic rhinitis • Patients who underwent minimally invasive selective PNN with or without associated procedures • Minimum postoperative follow-up period of one year Exclusion criteria: • Patients operated on less than one year prior to follow-up • Patients lost to follow-up Study Variable: Patients were evaluated through a structured questionnaire and were asked to compare preoperative and postoperative nasal symptoms, including: • Sneezing • Nasal itching • Rhinorrhoea • Nasal obstruction The Total Nasal Symptom Score (TNSS) was calculated for overall symptom assessment. Additional outcome measures included: • Postoperative medication score • Overall patient satisfaction with surgery Surgical Procedures Among the 34 patients analyzed: • PNN alone was performed in 19 cases (13 males, 6 females) • PNN with partial inferior turbinectomy was performed in 9 cases (7 males, 2 females) • PNN with partial inferior turbinectomy and septoplasty was performed in 6 cases (4 males, 2 females) Operative Technique All procedures were performed under general anesthesia using a minimally invasive endoscopic approach. A vertical incision was made just posterior to the posterior fontanelle in the middle meatus using monopolar cutting diathermy. A mucosal flap was elevated to expose the neurovascular bundle containing the posterior nasal nerve and sphenopalatine artery. The posterior nasal nerve was carefully identified and sectioned using a sickle knife or angled pick, while preserving the sphenopalatine artery. The cut end of the nerve was cauterized, and gelfoam was placed between the mucosal flap and the underlying bone to promote fibrosis. The mucosal flap was then repositioned. Statistical Analysis: For statistical analysis, data were initially entered into a Microsoft Excel spreadsheet and then analyzed using SPSS (version 27.0; SPSS Inc., Chicago, IL, USA) and GraphPad Prism (version 5). Numerical variables were summarized using means and standard deviations, while Data were entered into Excel and analyzed using SPSS and GraphPad Prism. Numerical variables were summarized using means and standard deviations, while categorical variables were described with counts and percentages. Two-sample t-tests were used to compare independent groups, while paired t-tests accounted for correlations in paired data. Chi-square tests (including Fisher’s exact test for small sample sizes) were used for categorical data comparisons. P-values ≤ 0.05 were considered statistically significant.

Table 1: Patient Demographics and Follow-up (n=34) Parameter n (%) Male 24 (70.6) Female 10 (29.4) Table 2: Type of Surgery Performed (n=34) Surgery Type n (%) PNN alone 19 (55.9) PNN + Partial Inferior Turbinectomy 9 (26.5) PNN + Partial Inferior Turbinectomy + Septoplasty 6 (17.6) Table 3: Preoperative vs Postoperative TNSS Scores (n=34) Symptom Preoperative Mean ± SD Postoperative Mean ± SD p-value Sneezing 2.8 ± 1.0 0.9 ± 0.5 <0.01 Rhinorrhoea 2.5 ± 0.9 0.7 ± 0.4 <0.01 Nasal Obstruction 2.4 ± 1.0 0.8 ± 0.5 <0.01 Itching 1.8 ± 0.8 0.5 ± 0.3 <0.01 TNSS Total 9.5 ± 2.4 2.9 ± 1.2 <0.01 Table 4: Preoperative vs Postoperative Medication Score (n=34) Parameter Preoperative Mean ± SD Postoperative Mean ± SD p-value Medication Score 1.6 ± 1.4 0.4 ± 0.5 <0.05 Table 5: Postoperative Outcomes by Duration (n=34) Symptom / Score 1–3 years n (%) 3–5 years n (%) p-value Sneezing (score ≤1) 16 (88.9) 14 (87.5) >0.05 Rhinorrhoea (score ≤1) 15 (83.3) 13 (81.3) >0.05 Nasal Obstruction (score ≤1) 16 (88.9) 14 (87.5) >0.05 TNSS Total ≤3 16 (88.9) 14 (87.5) >0.05 Medication Score 0–1 16 (88.9) 14 (87.5) >0.05 Table 6: Overall Patient Satisfaction Post-Surgery (n=34) Satisfaction Level n (%) Very satisfied 18 (52.9) Satisfied 12 (35.3) Neutral 4 (11.8) Out of the 34 participants who completed the study, 24 were male (70.6%) and 10 were female (29.4%), indicating that the study population was predominantly male. Out of the 34 patients who underwent surgery, 19 (55.9%) had PNN alone, 9 (26.5%) underwent PNN with partial inferior turbinectomy, and 6 (17.6%) received PNN combined with partial inferior turbinectomy and septoplasty, indicating that PNN alone was the most commonly performed procedure. In this study of 34 patients, preoperative TNSS scores were significantly higher across all symptoms compared to postoperative scores. Sneezing decreased from 2.8 ± 1.0 to 0.9 ± 0.5, rhinorrhoea from 2.5 ± 0.9 to 0.7 ± 0.4, nasal obstruction from 2.4 ± 1.0 to 0.8 ± 0.5, and itching from 1.8 ± 0.8 to 0.5 ± 0.3. The total TNSS score reduced from 9.5 ± 2.4 preoperatively to 2.9 ± 1.2 postoperatively, with all changes being statistically significant (p < 0.01), indicating a substantial improvement in allergic rhinitis symptoms following surgery. In this study of 34 patients, the preoperative medication score was 1.6 ± 1.4, which decreased to 0.4 ± 0.5 postoperatively. This reduction was statistically significant (p < 0.05), indicating that patients required substantially less medication for symptom control after surgery. Postoperative outcomes in 34 patients showed similar improvements regardless of the duration of follow-up. Among patients with 1–3 years of follow-up, sneezing, nasal obstruction, TNSS total ≤3, and medication score 0–1 were achieved in 16 patients (88.9%), and rhinorrhoea improved in 15 patients (83.3%). For those with 3–5 years of follow-up, corresponding outcomes were observed in 14 patients (87.5%) for all parameters except rhinorrhoea, which improved in 13 patients (81.3%). None of these differences were statistically significant (p > 0.05), indicating that postoperative improvements were sustained over time. Among the 34 patients who underwent surgery, 18 (52.9%) reported being very satisfied, 12 (35.3%) were satisfied, and 4 (11.8%) were neutral. This indicates that the majority of patients (88.2%) experienced a positive level of satisfaction following the procedure.

This retrospective, questionnaire-based follow-up study evaluated the postoperative outcomes of minimally invasive selective posterior nasal neurectomy (PNN) in patients with severe perennial allergic rhinitis. Conducted at the Department of Otorhinolaryngology, IPGME&R, Kolkata, West Bengal, India, between 01 July 2020 and 30 June 2025, the study included 34 patients (24 males and 10 females) who completed the follow-up and were included in the final analysis. In this study of 34 patients undergoing posterior nasal neurectomy (PNN) with or without adjunct procedures, the majority of participants were male (70.6%), reflecting a slightly higher prevalence of treatment-seeking among men, consistent with previous reports (Lee ML et al., 2023 [6]; Balai E et al., 2023 [7]). The most commonly performed procedure was PNN alone (55.9%), followed by PNN combined with partial inferior turbinectomy (26.5%) and PNN with both partial inferior turbinectomy and septoplasty (17.6%), indicating that isolated PNN is often sufficient for symptomatic relief in allergic rhinitis (Senanayake P et al., 2022 [8]; Takahara D et al., 2017 [9]). Significant improvements were observed in TNSS scores postoperatively across all symptom domains. Sneezing decreased from 2.8 ± 1.0 to 0.9 ± 0.5, rhinorrhoea from 2.5 ± 0.9 to 0.7 ± 0.4, nasal obstruction from 2.4 ± 1.0 to 0.8 ± 0.5, and itching from 1.8 ± 0.8 to 0.5 ± 0.3. The total TNSS score reduced from 9.5 ± 2.4 preoperatively to 2.9 ± 1.2 postoperatively (p < 0.01), demonstrating substantial symptomatic improvement, which aligns with findings from Sonoda S et al., 2021 [11,12] and Ogi K et al., 2019 [13] who reported long-term efficacy of PNN in chronic rhinitis. The preoperative medication score of 1.6 ± 1.4 decreased significantly to 0.4 ± 0.5 postoperatively (p < 0.05), indicating that surgery substantially reduced the need for pharmacotherapy. Similar findings have been reported by Ogawa T et al., 2007 [14] and Chen M et al., 2022 [15], emphasizing that PNN, with or without submucosal turbinectomy, can effectively reduce medication dependence in patients with severe allergic rhinitis. Postoperative outcomes were sustained over time. In patients with 1–3 years of follow-up, 88.9% achieved TNSS total ≤3 and a medication score of 0–1, while patients with 3–5 years of follow-up maintained comparable improvements (87.5%), with no statistically significant difference between the two groups (p > 0.05). These results suggest long-term stability of symptom relief and medication reduction, corroborating the findings of Kamimura S et al., 2024 [17] regarding the durable effectiveness of PNN. Patient satisfaction was high, with 52.9% reporting being very satisfied and 35.3% satisfied postoperatively, indicating that 88.2% of patients experienced a positive outcome. This high satisfaction rate reflects both symptom improvement and decreased medication burden, as noted in prior studies (Lee ML et al., 2023 [6]; Sonoda S et al., 2021 [11]; Ogi K et al., 2019 [13]). Overall, this study demonstrates that PNN, alone or combined with adjunctive procedures, provides effective, sustained relief in patients with allergic rhinitis, significantly reduces the need for medications, and achieves high patient satisfaction. These findings are consistent with existing literature, supporting PNN as a safe and effective surgical option for patients with refractory allergic rhinitis (Lee ML et al., 2023 [6]–Kamimura S et al., 2024 [17]).

In conclusion, minimally invasive selective posterior nasal neurectomy (PNN) is an effective and safe treatment for patients with severe perennial allergic rhinitis. The procedure, whether performed alone or combined with partial inferior turbinectomy and/or septoplasty, leads to significant and sustained improvement in key symptoms such as sneezing, rhinorrhoea, nasal obstruction, and itching, as reflected by a marked reduction in total TNSS scores. It also substantially decreases the need for medications, demonstrating its role in long-term symptom control. Postoperative benefits are maintained over follow-up periods of 1–5 years, with consistent outcomes regardless of duration, and the majority of patients report high levels of satisfaction. These findings support minimally invasive PNN as a valuable surgical option for refractory allergic rhinitis, providing durable symptom relief, reduced medication dependence, and improved quality of life.

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