ORIGINAL ARTICLE
Endoscopic vidian neurectomy: a prospective case series Han Zhang, MD1 , Damian C. Micomonaco, MD, FRCSC2 , Peter T. Dziegielewski, MD, FRCSC3 , Leigh J. Sowerby, MD, FRCSC4 , Ezekiel Weis, MD, FRCSC5 and Erin D. Wright, MDCM, MEd, FRCSC1
Background: Chronic refractory vasomotor rhinitis (VMR) is a debilitating condition that causes significant impairment of quality of life. The purpose of this study is to investigate the efficacy and potential side effects of endoscopic vidian neurectomy as treatment for patients with VMR. Methods: This study was a prospective, intent-to-follow case series. Inclusion criteria were as follows: (1) patients with debilitating VMR refractory to medical therapy and with significant impact on quality of life; (2) negative allergy history and skin testing; and (3) negative computed tomography (CT) scan to rule out skull-base defect or cerebrospinal fluid (CSF) fistula. Patients underwent bilateral vidian neurectomy via a pterygomaxillary approach. Prior to surgery all patients underwent formal ophthalmologic testing to quantify preoperative ocular and lacrimal function. Ophthalmologic testing was repeated postoperatively at approximately 3 months. Patients also completed surveys regarding rhinologic outcomes including the Sinusitis Symptom Questionnaire (SSQ) and the 22-item Sino-Nasal Outcome Test (SNOT-22) at the following time points: preoperatively, and 1 week, 4 weeks, 12 weeks, 6 months, 1 year, and 2 years postsurgery. Descriptive statistics and analysis of variance (ANOVA) were undertaken.
tion in all cases. Average follow-up was 19.4 months. Statistically and clinically significant improvement was measured for both the SSQ and the SNOT-22 and compared with the patients’ baseline scores (p < 0.0001). Subscores for rhinorrhea and nasal congestions were also statistically significantly improved (p < 0.05). No incidence of permanent or measureable dry eye has been reported. Conclusion: The data suggests that vidian neurectomy is an effective, safe, and definitive treatment for most patients C 2015 ARSwith VMR refractory to medical treatment. AAOA, LLC.
Key Words: endoscopic vidian neurectomy; nonallergic rhinitis; vasomotor rhinitis; vidian nerve; rhinorrhea How to Cite this Article: Zhang H, Micomonaco DC, Dziegielewski PT, Sowerby LJ, Weis E, Wright ED. Endoscopic vidian neurectomy: a prospective case series. Int Forum Allergy Rhinol. 2015;5:423–430.
Results: Eleven patients (22 sides) underwent bilateral vidian neurectomy with pathologic confirmation of nerve sec-
G
1 Division
of Otolaryngology–Head and Neck Surgery, University of Alberta, Edmonton, Alberta, Canada; 2 Department of Surgery, Northern Ontario School of Medicine, Thunder Bay, Ontario, Canada; 3 Department of Otolaryngology–Head and Neck Surgery, University of Florida, Gainesville, FL; 4 Department of Otolaryngology–Head and Neck Surgery, Western University, London, Ontario, Canada; 5 Division of Ophthalmology, University of Alberta, Edmonton, Alberta, Canada Correspondence to: Erin D. Wright, MDCM, MEd, FRCSC, Division of Otolaryngology–Head and Neck Surgery, University of Alberta, Edmonton, Alberta, Canada; e-mail: [email protected] Potential conflict of interest: None provided. Presented at the 2014 Annual ARS Meeting on September 20, 2014, in Orlando, FL. Received: 21 August 2014; Revised: 16 October 2014; Accepted: 23 October 2014 DOI: 10.1002/alr.21462 View this article online at wileyonlinelibrary.com.
423
International Forum of Allergy & Rhinology, Vol. 5, No. 5, May 2015
ustatory rhinitis, also known more commonly as vasomotor rhinitis (VMR) is a form of chronic, nonallergic, noninflammatory rhinitis of unknown origin.1 It is a debilitating syndrome often characterized by the acute onset of copious watery rhinorrhea, sneezing, nasal obstruction, and postnasal drip often in response to environmental stimuli.2 These stimuli typically include chemical irritants, hormonal or emotional changes, and or select medications. Diagnosis of VMR is usually based on the patient’s symptomatology and signs, as well as negative allergy testing.1, 2 VMR is not uncommon and can be a debilitating condition causing intractable clear rhinorrhea and social embarrassment with a profound affect on quality of life. The treatment includes stimulant avoidance and medications. Anticholinergic nasal sprays, antihistamines, topical nasal steroids, and capsaicin make up the majority of medicinal
Zhang et al.
options. The outcomes of these therapeutic interventions have been met with variable benefit.1–4 Vidian neurectomy was first described by GoldingWood5 in the early 1960s for the management of intractable VMR. Effectiveness of the procedure is based on the theory that VMR represents an imbalance between the parasympathetic and sympathetic nasal innervation.1 This then causes stimulation of the goblet cells and mucosal glands with intractable watery rhinorrhea. Resecting or dividing the vidian nerve allows for disruption of the autonomic nerve supply, thus theoretically reducing the nasal secretions. In the past, challenges with accurate visualization of the vidian nerve as well as potential orbital complications and unsatisfactory long-term outcomes has resulted in the surgery being done rather selectively.6 However, advancements in endoscopic sinus technology, refinements in surgical technique, and better outcomes assessments in the past decades has sparked a new interest in this potentially useful surgical intervention in medically refractory cases.7 Since Kamel and Zaher8 first described the use of endoscopic approaches to the vidian canal in a cadaver model, only a select few case series have shown great success with this novel technique.6, 9 However, these studies notably lacked the use of validated outcomes measures and were of a retrospective study design prompting the need for a prospective case series with proven quantitative outcome measures. It is therefore our objective to investigate the long-term efficacy and safety of endoscopic vidian neurectomy as treatment for medically refractory VMR in a North American population.
Patients and methods The University of Alberta’s Health Research Ethics Board (HREB) reviewed the study and granted its approval. This study was designed as a single-institution, prospective case series with an intention-to-follow.
Patients All patients clinically diagnosed with VMR at the Alberta Sinus Center at the University of Alberta, Edmonton, Canada, between February 2010 and February 2014 were considered candidates for recruitment. Inclusion criteria was set as: (1) patients with debilitating VMR refractory to medical therapy and with significant impact on quality of life; (2) negative allergy history and skin testing; and (3) negative computed tomography (CT) scan to rule out skull-base defect/cerebrospinal fluid (CSF) fistula. Patients were asked to grade their symptoms of nasal obstruction, rhinorrhea, sneezing, and postnasal drip using the 22-item Sino-Nasal Outcome Test (SNOT-22)10 and the Sinus Symptom Questionnaire (SSQ) visual analogue scale at the following time points: preoperatively, as well as 1 week, 4 weeks, 12 weeks, 6 months, 1 year, and 2 years postsurgery. Prior to the operation all patients underwent
formal ophthalmologic testing by a single ophthalmologist (E.W.) to quantify preoperative lacrimal function. Ophthalmologic testing was repeated after the surgery at approximately 3 months. Postoperatively patients were also asked regarding symptoms of: dry eyes, visual disturbances, and reflex tearing.
Outcome measures Primary outcome was set as improvements in sinonasal symptoms as measured by SNOT-22 and SSQ questionnaires from prior to the operation to after. SNOT-22 is a 22-item questionnaire that is a modification of the previously validated SNOT-20. It has been validated as a measure of rhinosinusitis health status, quality of life, and outcomes of surgical intervention. It has been proven to not only accurately describe health burden and symptomatology but is also sensitive to clinical change.10
Surgical technique After informed consent, all patients received bilateral endoscopic vidian neurectomies via a pterygomaxillary fossa approach9 by the senior author (E.D.W.) at the University of Alberta Hospital. The FUSION ENT Navigation system (Medtronic, Mississauga, ON, Canada) was used for all procedures. After induction of general anesthesia and intubation, cotton pledgets soaked with 1 mL of 1:1000 adrenaline was used for topical nasal preparation. A 0-degree and 30-degree 4-mm rigid Storz Endoscope (Karl Storz, Tuttlingen, Germany) were used for the operation. Local anesthesia using 1% with 1:100,000 adrenaline was then injected at the lateral nasal wall over the region of the sphenopalatine foramen. A C-shaped mucosal incision is then made with the base centered over the sphenopalatine foramen (Fig. 1A). Elevation of the mucosa is then done with a Cottle elevator. The sphenopalatine artery and any branches is then identified, cauterized with bipolar diathermy, and divided. This is an important step because the nasoseptal branch of the artery typically travels across the face of the sphenoid, thus its ligation prevents hemorrhagic obstruction of the operative field of view. Having thus identified the sphenopalatine foramen, the mucosal flap is then raised behind the foramen until the anterior face of the sphenoid sinus is identified. A Kerrison’s punch or Cottle elevator is then used to remove/downfracture the inferior and posterior bone enlarging the sphenopalatine foramen posteriorly up to the anterior face of the sphenoid to the level of the floor of the sphenoid, exposing the periosteum of the underlying pterygopalatine fossa (Fig. 1B). A sphenoidotomy can be performed at this point to aid in orientation to the vidian canal; however, we no longer routinely use this adjunct but rather reserve it for times when it is useful. The vidian nerve typically courses along the floor of the sphenoid sinus within the vidian canal. A sickle knife is then used to incise the periosteum funneling into the vidian canal. After exposing the fat of the pterygopalatine fossa, the vidian nerve is isolated and
International Forum of Allergy & Rhinology, Vol. 5, No. 5, May 2015
424
Endoscopic Vidian Neurectomy
TABLE 1. Patient variables Patients, n (sides operated)
11 (22)
Age, years Mean
45.7
Range
25–86
Standard deviation
19.2
Gender, n (%) Male
7 (63.6)
Female
4 (36.4)
dissected out of the fat. The nerve is then confirmed as it is followed anteriorly as it turns laterally to synapse with the pterygopalatine ganglion (Fig. 1C). The vidian nerve is then divided with microscissors on either side and a 3-mm to 4-mm portion of the nerve is removed. All vidian nerves removed were sent for histology and were pathologically confirmed postoperatively. The mucosal flap is then replaced over the area of dissection. A single 2-cm to 4-cm Nasopore (Polyganics, Groningen, The Netherlands) is placed in the middle meatus along the lateral nasal wall for packing. The same procedure is then completed on the contralateral side.
Follow-up All patients were followed at the Alberta Sinus Center by the senior author (E.D.W.) for up to 2 years after their surgery. Follow-up at approximately 3 months postoperatively was also completed with a single ophthalmologist (E.W.). All follow-up through August 2014 was recorded.
Statistical analysis Descriptive statistics were used for patients’ parameters (mean, range, standard deviation). Continuous data was analyzed using analysis of variance (ANOVA). Comparison of proportions was performed using the chi-squared test. Level of significance was set as p < 0.05. Analyses were performed with SPSS Statistics 20.0 (SPSS Inc, Chicago, IL).
Results
FIGURE 1. (A) Raising of a C-shaped mucosal flap over the sphenopalatine foramen. (B) Periosteum incised over the PPF. (C) Exposure of the VN. PPF = pterygopalatine fossa; VN = vidian nerve.
Eleven patients underwent bilateral endoscopic vidian neurectomy by the senior author (E.W.D.) between February 2010 and February 2014 at the University of Alberta Hospital (Edmonton, Alberta, Canada) and all were included in the study. In all cases bilateral endoscopic vidian neurectomies were completed (22 sides).
Patient variables Table 1 shows patient demographic variables. Mean ± standard deviation (SD) age was found to be 45.7 ± 19.2 years. Most of the patients were male (63.6%). Patient follow-up is summarized in Table 2. Mean follow-up was
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International Forum of Allergy & Rhinology, Vol. 5, No. 5, May 2015
Zhang et al.
TABLE 2. Patient follow-up Follow-up, months Mean
19.4
Range
12.4–25.2
Standard deviation
5.2
found to be 19.4 months among the 11 patients (range, 12.4 to 25.2 months).
Sinonasal symptoms outcomes Sinonasal symptoms were measured using the SSQ and SNOT-22 questionnaire tools completed preoperatively as baseline then postoperatively at 1 week, 6 weeks, 3 months, 6 months, 1 year, and 2 years. All patients had
significant baseline sinusitis symptoms with average SSQ and SNOT-22 scores at 33.3 and 44.8, respectively, as shown in Figures 2 and 3. Rhinorrhea and congestion were dominant symptoms with SSQ preoperative scores of 8.0 and 5.0, respectively (Fig. 4A,B). All patients showed significant improvement in average SSQ and SNOT-22 scores 1 week after the operation as shown in Figures 2 and 3. Rhinorrhea was the most improved subscore with SSQ and SNOT-22 improvements of 4.4 and 1.7, respectively (Fig. 4A, 5A). One patient had a recurrence of his symptoms to baseline at 6 months postoperatively. The other 10 patients had gradual improvement in rhinorrhea and congestion up to 2 years follow-up duration. Figures 1 and 2 shows average SSQ and SNOT-22 scores at 2-year follow-up to be 2.8 and 10.2, respectively. One-way ANOVA as shown in Table 3 shows that all subscores within the SSQ and SNOT-22 questionnaire met statistical significance (p < 0.05).
FIGURE 2. SSQ values at time periods indicated. Pre-op = preoperation; Post-op = postoperation; SSQ = Sinusitis Symptom Questionnaire; wk = week.
FIGURE 3. SNOT-22 values at time periods indicated. Pre-op = preoperation; Post-op = postoperation; SNOT-22 = 22 item Sino-Nasal Outcomes Test; wk = week.
International Forum of Allergy & Rhinology, Vol. 5, No. 5, May 2015
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Endoscopic Vidian Neurectomy
FIGURE 4. (A) SSQ: Rhinorrhea Component values at time periods indicated. (B) SNOT-22: Rhinorrhea Component values at time periods indicated. Pre-op = preoperation; Post-op = postoperation; SNOT-22 = 22-item Sino-Nasal Outcome Test; SSQ = Sinusitis Symptom Questionnaire; wk = week.
Ophthalmologic outcomes All patients received ophthalmologic assessment (E.W.) prior to their operations and at approximately 3 months afterward. At baseline, 1 patient was found to have existing dry eye as a result of a diagnosis of glaucoma. Postoperatively, no new cases of dry eye were elicited. All patients were also found to have a reduced tear reflex.
Discussion After its first description in the 1960s, vidian neurectomy had been largely abandoned mainly due to difficulties with the accurate localization of the vidian nerve as well as reported unsatisfactory long-term outcomes.7 Most patients previously reported a return of symptoms within 2 years. A small number of studies in the past 2 decades, however, have revisited the use of vidian neurectomy through an
427
International Forum of Allergy & Rhinology, Vol. 5, No. 5, May 2015
endoscopic approach. Robinson and Wormald9 as well as Lee et al.6 have described better long-term symptom control using specific approaches endoscopically. These findings, while being useful additions to the literature, are limited to a non–North American demographic and also suffer from the usage of nonvalidated sinonasal symptom questionnaires. We therefore sought to bridge the gap in the literature with a prospective intent-to-follow case series using validated symptom questionnaires, and perhaps more importantly, with prospective assessment of potential ocular side effects. Previous studies have shown variable improvements in rhinorrhea and nasal congestion after undergoing bilateral endoscopic vidian neurectomies. Robinson and Wormald9 reported significant improvement in both rhinorrhea and nasal obstruction but no significant changes in sneezing or postnasal drip in 9 patients (14 sides) with vasomotor rhinitis. Similar results were achieved by Jang et al.11 and Lee et al.6 Jang et al.11 reported improvements in
Zhang et al.
FIGURE 5. (A) SSQ: Congestion Component values at time periods indicated. (B) SNOT-22: Congestion Component values at time periods indicated. Pre-op = preoperation; Post-op = postoperation; SNOT-22 = 22-item Sino-Nasal Outcome Test; SSQ = Sinusitis Symptom Questionnaire; wk = week.
6 patients following surgery with a 7-year follow-up while Lee et al.,6 who reported the largest retrospective series to TABLE 3. One-way analysis of variance Groups
p
SSQ Average
Endoscopic vidian neurectomy: a prospective case series Han Zhang, MD1 , Damian C. Micomonaco, MD, FRCSC2 , Peter T. Dziegielewski, MD, FRCSC3 , Leigh J. Sowerby, MD, FRCSC4 , Ezekiel Weis, MD, FRCSC5 and Erin D. Wright, MDCM, MEd, FRCSC1
Background: Chronic refractory vasomotor rhinitis (VMR) is a debilitating condition that causes significant impairment of quality of life. The purpose of this study is to investigate the efficacy and potential side effects of endoscopic vidian neurectomy as treatment for patients with VMR. Methods: This study was a prospective, intent-to-follow case series. Inclusion criteria were as follows: (1) patients with debilitating VMR refractory to medical therapy and with significant impact on quality of life; (2) negative allergy history and skin testing; and (3) negative computed tomography (CT) scan to rule out skull-base defect or cerebrospinal fluid (CSF) fistula. Patients underwent bilateral vidian neurectomy via a pterygomaxillary approach. Prior to surgery all patients underwent formal ophthalmologic testing to quantify preoperative ocular and lacrimal function. Ophthalmologic testing was repeated postoperatively at approximately 3 months. Patients also completed surveys regarding rhinologic outcomes including the Sinusitis Symptom Questionnaire (SSQ) and the 22-item Sino-Nasal Outcome Test (SNOT-22) at the following time points: preoperatively, and 1 week, 4 weeks, 12 weeks, 6 months, 1 year, and 2 years postsurgery. Descriptive statistics and analysis of variance (ANOVA) were undertaken.
tion in all cases. Average follow-up was 19.4 months. Statistically and clinically significant improvement was measured for both the SSQ and the SNOT-22 and compared with the patients’ baseline scores (p < 0.0001). Subscores for rhinorrhea and nasal congestions were also statistically significantly improved (p < 0.05). No incidence of permanent or measureable dry eye has been reported. Conclusion: The data suggests that vidian neurectomy is an effective, safe, and definitive treatment for most patients C 2015 ARSwith VMR refractory to medical treatment. AAOA, LLC.
Key Words: endoscopic vidian neurectomy; nonallergic rhinitis; vasomotor rhinitis; vidian nerve; rhinorrhea How to Cite this Article: Zhang H, Micomonaco DC, Dziegielewski PT, Sowerby LJ, Weis E, Wright ED. Endoscopic vidian neurectomy: a prospective case series. Int Forum Allergy Rhinol. 2015;5:423–430.
Results: Eleven patients (22 sides) underwent bilateral vidian neurectomy with pathologic confirmation of nerve sec-
G
1 Division
of Otolaryngology–Head and Neck Surgery, University of Alberta, Edmonton, Alberta, Canada; 2 Department of Surgery, Northern Ontario School of Medicine, Thunder Bay, Ontario, Canada; 3 Department of Otolaryngology–Head and Neck Surgery, University of Florida, Gainesville, FL; 4 Department of Otolaryngology–Head and Neck Surgery, Western University, London, Ontario, Canada; 5 Division of Ophthalmology, University of Alberta, Edmonton, Alberta, Canada Correspondence to: Erin D. Wright, MDCM, MEd, FRCSC, Division of Otolaryngology–Head and Neck Surgery, University of Alberta, Edmonton, Alberta, Canada; e-mail: [email protected] Potential conflict of interest: None provided. Presented at the 2014 Annual ARS Meeting on September 20, 2014, in Orlando, FL. Received: 21 August 2014; Revised: 16 October 2014; Accepted: 23 October 2014 DOI: 10.1002/alr.21462 View this article online at wileyonlinelibrary.com.
423
International Forum of Allergy & Rhinology, Vol. 5, No. 5, May 2015
ustatory rhinitis, also known more commonly as vasomotor rhinitis (VMR) is a form of chronic, nonallergic, noninflammatory rhinitis of unknown origin.1 It is a debilitating syndrome often characterized by the acute onset of copious watery rhinorrhea, sneezing, nasal obstruction, and postnasal drip often in response to environmental stimuli.2 These stimuli typically include chemical irritants, hormonal or emotional changes, and or select medications. Diagnosis of VMR is usually based on the patient’s symptomatology and signs, as well as negative allergy testing.1, 2 VMR is not uncommon and can be a debilitating condition causing intractable clear rhinorrhea and social embarrassment with a profound affect on quality of life. The treatment includes stimulant avoidance and medications. Anticholinergic nasal sprays, antihistamines, topical nasal steroids, and capsaicin make up the majority of medicinal
Zhang et al.
options. The outcomes of these therapeutic interventions have been met with variable benefit.1–4 Vidian neurectomy was first described by GoldingWood5 in the early 1960s for the management of intractable VMR. Effectiveness of the procedure is based on the theory that VMR represents an imbalance between the parasympathetic and sympathetic nasal innervation.1 This then causes stimulation of the goblet cells and mucosal glands with intractable watery rhinorrhea. Resecting or dividing the vidian nerve allows for disruption of the autonomic nerve supply, thus theoretically reducing the nasal secretions. In the past, challenges with accurate visualization of the vidian nerve as well as potential orbital complications and unsatisfactory long-term outcomes has resulted in the surgery being done rather selectively.6 However, advancements in endoscopic sinus technology, refinements in surgical technique, and better outcomes assessments in the past decades has sparked a new interest in this potentially useful surgical intervention in medically refractory cases.7 Since Kamel and Zaher8 first described the use of endoscopic approaches to the vidian canal in a cadaver model, only a select few case series have shown great success with this novel technique.6, 9 However, these studies notably lacked the use of validated outcomes measures and were of a retrospective study design prompting the need for a prospective case series with proven quantitative outcome measures. It is therefore our objective to investigate the long-term efficacy and safety of endoscopic vidian neurectomy as treatment for medically refractory VMR in a North American population.
Patients and methods The University of Alberta’s Health Research Ethics Board (HREB) reviewed the study and granted its approval. This study was designed as a single-institution, prospective case series with an intention-to-follow.
Patients All patients clinically diagnosed with VMR at the Alberta Sinus Center at the University of Alberta, Edmonton, Canada, between February 2010 and February 2014 were considered candidates for recruitment. Inclusion criteria was set as: (1) patients with debilitating VMR refractory to medical therapy and with significant impact on quality of life; (2) negative allergy history and skin testing; and (3) negative computed tomography (CT) scan to rule out skull-base defect/cerebrospinal fluid (CSF) fistula. Patients were asked to grade their symptoms of nasal obstruction, rhinorrhea, sneezing, and postnasal drip using the 22-item Sino-Nasal Outcome Test (SNOT-22)10 and the Sinus Symptom Questionnaire (SSQ) visual analogue scale at the following time points: preoperatively, as well as 1 week, 4 weeks, 12 weeks, 6 months, 1 year, and 2 years postsurgery. Prior to the operation all patients underwent
formal ophthalmologic testing by a single ophthalmologist (E.W.) to quantify preoperative lacrimal function. Ophthalmologic testing was repeated after the surgery at approximately 3 months. Postoperatively patients were also asked regarding symptoms of: dry eyes, visual disturbances, and reflex tearing.
Outcome measures Primary outcome was set as improvements in sinonasal symptoms as measured by SNOT-22 and SSQ questionnaires from prior to the operation to after. SNOT-22 is a 22-item questionnaire that is a modification of the previously validated SNOT-20. It has been validated as a measure of rhinosinusitis health status, quality of life, and outcomes of surgical intervention. It has been proven to not only accurately describe health burden and symptomatology but is also sensitive to clinical change.10
Surgical technique After informed consent, all patients received bilateral endoscopic vidian neurectomies via a pterygomaxillary fossa approach9 by the senior author (E.D.W.) at the University of Alberta Hospital. The FUSION ENT Navigation system (Medtronic, Mississauga, ON, Canada) was used for all procedures. After induction of general anesthesia and intubation, cotton pledgets soaked with 1 mL of 1:1000 adrenaline was used for topical nasal preparation. A 0-degree and 30-degree 4-mm rigid Storz Endoscope (Karl Storz, Tuttlingen, Germany) were used for the operation. Local anesthesia using 1% with 1:100,000 adrenaline was then injected at the lateral nasal wall over the region of the sphenopalatine foramen. A C-shaped mucosal incision is then made with the base centered over the sphenopalatine foramen (Fig. 1A). Elevation of the mucosa is then done with a Cottle elevator. The sphenopalatine artery and any branches is then identified, cauterized with bipolar diathermy, and divided. This is an important step because the nasoseptal branch of the artery typically travels across the face of the sphenoid, thus its ligation prevents hemorrhagic obstruction of the operative field of view. Having thus identified the sphenopalatine foramen, the mucosal flap is then raised behind the foramen until the anterior face of the sphenoid sinus is identified. A Kerrison’s punch or Cottle elevator is then used to remove/downfracture the inferior and posterior bone enlarging the sphenopalatine foramen posteriorly up to the anterior face of the sphenoid to the level of the floor of the sphenoid, exposing the periosteum of the underlying pterygopalatine fossa (Fig. 1B). A sphenoidotomy can be performed at this point to aid in orientation to the vidian canal; however, we no longer routinely use this adjunct but rather reserve it for times when it is useful. The vidian nerve typically courses along the floor of the sphenoid sinus within the vidian canal. A sickle knife is then used to incise the periosteum funneling into the vidian canal. After exposing the fat of the pterygopalatine fossa, the vidian nerve is isolated and
International Forum of Allergy & Rhinology, Vol. 5, No. 5, May 2015
424
Endoscopic Vidian Neurectomy
TABLE 1. Patient variables Patients, n (sides operated)
11 (22)
Age, years Mean
45.7
Range
25–86
Standard deviation
19.2
Gender, n (%) Male
7 (63.6)
Female
4 (36.4)
dissected out of the fat. The nerve is then confirmed as it is followed anteriorly as it turns laterally to synapse with the pterygopalatine ganglion (Fig. 1C). The vidian nerve is then divided with microscissors on either side and a 3-mm to 4-mm portion of the nerve is removed. All vidian nerves removed were sent for histology and were pathologically confirmed postoperatively. The mucosal flap is then replaced over the area of dissection. A single 2-cm to 4-cm Nasopore (Polyganics, Groningen, The Netherlands) is placed in the middle meatus along the lateral nasal wall for packing. The same procedure is then completed on the contralateral side.
Follow-up All patients were followed at the Alberta Sinus Center by the senior author (E.D.W.) for up to 2 years after their surgery. Follow-up at approximately 3 months postoperatively was also completed with a single ophthalmologist (E.W.). All follow-up through August 2014 was recorded.
Statistical analysis Descriptive statistics were used for patients’ parameters (mean, range, standard deviation). Continuous data was analyzed using analysis of variance (ANOVA). Comparison of proportions was performed using the chi-squared test. Level of significance was set as p < 0.05. Analyses were performed with SPSS Statistics 20.0 (SPSS Inc, Chicago, IL).
Results
FIGURE 1. (A) Raising of a C-shaped mucosal flap over the sphenopalatine foramen. (B) Periosteum incised over the PPF. (C) Exposure of the VN. PPF = pterygopalatine fossa; VN = vidian nerve.
Eleven patients underwent bilateral endoscopic vidian neurectomy by the senior author (E.W.D.) between February 2010 and February 2014 at the University of Alberta Hospital (Edmonton, Alberta, Canada) and all were included in the study. In all cases bilateral endoscopic vidian neurectomies were completed (22 sides).
Patient variables Table 1 shows patient demographic variables. Mean ± standard deviation (SD) age was found to be 45.7 ± 19.2 years. Most of the patients were male (63.6%). Patient follow-up is summarized in Table 2. Mean follow-up was
425
International Forum of Allergy & Rhinology, Vol. 5, No. 5, May 2015
Zhang et al.
TABLE 2. Patient follow-up Follow-up, months Mean
19.4
Range
12.4–25.2
Standard deviation
5.2
found to be 19.4 months among the 11 patients (range, 12.4 to 25.2 months).
Sinonasal symptoms outcomes Sinonasal symptoms were measured using the SSQ and SNOT-22 questionnaire tools completed preoperatively as baseline then postoperatively at 1 week, 6 weeks, 3 months, 6 months, 1 year, and 2 years. All patients had
significant baseline sinusitis symptoms with average SSQ and SNOT-22 scores at 33.3 and 44.8, respectively, as shown in Figures 2 and 3. Rhinorrhea and congestion were dominant symptoms with SSQ preoperative scores of 8.0 and 5.0, respectively (Fig. 4A,B). All patients showed significant improvement in average SSQ and SNOT-22 scores 1 week after the operation as shown in Figures 2 and 3. Rhinorrhea was the most improved subscore with SSQ and SNOT-22 improvements of 4.4 and 1.7, respectively (Fig. 4A, 5A). One patient had a recurrence of his symptoms to baseline at 6 months postoperatively. The other 10 patients had gradual improvement in rhinorrhea and congestion up to 2 years follow-up duration. Figures 1 and 2 shows average SSQ and SNOT-22 scores at 2-year follow-up to be 2.8 and 10.2, respectively. One-way ANOVA as shown in Table 3 shows that all subscores within the SSQ and SNOT-22 questionnaire met statistical significance (p < 0.05).
FIGURE 2. SSQ values at time periods indicated. Pre-op = preoperation; Post-op = postoperation; SSQ = Sinusitis Symptom Questionnaire; wk = week.
FIGURE 3. SNOT-22 values at time periods indicated. Pre-op = preoperation; Post-op = postoperation; SNOT-22 = 22 item Sino-Nasal Outcomes Test; wk = week.
International Forum of Allergy & Rhinology, Vol. 5, No. 5, May 2015
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Endoscopic Vidian Neurectomy
FIGURE 4. (A) SSQ: Rhinorrhea Component values at time periods indicated. (B) SNOT-22: Rhinorrhea Component values at time periods indicated. Pre-op = preoperation; Post-op = postoperation; SNOT-22 = 22-item Sino-Nasal Outcome Test; SSQ = Sinusitis Symptom Questionnaire; wk = week.
Ophthalmologic outcomes All patients received ophthalmologic assessment (E.W.) prior to their operations and at approximately 3 months afterward. At baseline, 1 patient was found to have existing dry eye as a result of a diagnosis of glaucoma. Postoperatively, no new cases of dry eye were elicited. All patients were also found to have a reduced tear reflex.
Discussion After its first description in the 1960s, vidian neurectomy had been largely abandoned mainly due to difficulties with the accurate localization of the vidian nerve as well as reported unsatisfactory long-term outcomes.7 Most patients previously reported a return of symptoms within 2 years. A small number of studies in the past 2 decades, however, have revisited the use of vidian neurectomy through an
427
International Forum of Allergy & Rhinology, Vol. 5, No. 5, May 2015
endoscopic approach. Robinson and Wormald9 as well as Lee et al.6 have described better long-term symptom control using specific approaches endoscopically. These findings, while being useful additions to the literature, are limited to a non–North American demographic and also suffer from the usage of nonvalidated sinonasal symptom questionnaires. We therefore sought to bridge the gap in the literature with a prospective intent-to-follow case series using validated symptom questionnaires, and perhaps more importantly, with prospective assessment of potential ocular side effects. Previous studies have shown variable improvements in rhinorrhea and nasal congestion after undergoing bilateral endoscopic vidian neurectomies. Robinson and Wormald9 reported significant improvement in both rhinorrhea and nasal obstruction but no significant changes in sneezing or postnasal drip in 9 patients (14 sides) with vasomotor rhinitis. Similar results were achieved by Jang et al.11 and Lee et al.6 Jang et al.11 reported improvements in
Zhang et al.
FIGURE 5. (A) SSQ: Congestion Component values at time periods indicated. (B) SNOT-22: Congestion Component values at time periods indicated. Pre-op = preoperation; Post-op = postoperation; SNOT-22 = 22-item Sino-Nasal Outcome Test; SSQ = Sinusitis Symptom Questionnaire; wk = week.
6 patients following surgery with a 7-year follow-up while Lee et al.,6 who reported the largest retrospective series to TABLE 3. One-way analysis of variance Groups
p
SSQ Average
