Archives of
Oto-Rhino-Laryngology
Arch. Otorhinolaryngol. 225, 67--77 (1979)
9 Springer-Verlag 1979
Vidian Neurectomy for Allergic Rhinitis Evaluation of Long-term Results and Some Problems Concerning Operative Therapy Akiyoshi Konno and Kiyoshi Togawa Department of Otorhinolaryngology,Akita University, School of Medicine, 1-1-1 Hondo, Akita City, Akita Pref., Japan
Summary. Vidian neurectomy was performed in 28 patients with perennial nasal allergy and changes in symptoms and complications 3 - 7 years after the operation were examined in order to evaluate the effect and limitation of the operative therapy on nasal allergy. Vidian neurectomy could completely stop hyperrhinorrhea in all cases for a limited period of time. In 43% cases, however, recurrence of rhinorrhea was observed. As for nasal obstruction, disappearance of the symptom or marked improvement was noted in only 33% of the cases and in many eases, intranasal operation was also required for improvement of nasal obstruction. Disappearance of nasal obstruction and marked improvement when intranasal operation was also applied was noted in 85% of cases. If the grade one improvement was included, general improvement of the symptoms of nasal allergy lasted in 8 6 - 9 0 % of the cases. Effect of operative removal of sneezing, nasal obstruction, and rhinorrhea which are considered to be defensive reflex, on lower airway or whole body was examined by pulmonary function tests and measurement of serum total IgE level. There were no postoperative tendency to development of obstructive ventilatory impairment at the lower airway or to increase in serum total IgE level. There is room to improve the operative technique to inhibit reinnervation, however, the merit of Vidian neurectomy is large for selected patients with perennial nasal allergy, because when combined with intranasal operation to relieve nasal obstruction it can remove the symptoms in high percentage of cases by a single performance. Key words: Nasal allergy - Vidian neurectomy
Since Golding Wood (1961) reported Vidian neurectomy as an operative therapy for vasomotor rhinitis, this method has been tried in many hospitals for vasomotor rhinitis and dramatic clinical effects have been reported. Recently, the indication has been widened and this method has been carried out also for nasal allergy (Noruma et al., 1972; Takahashi et al., 1970; Togawa et al., 1971). However, with spread of this operative technique, several secondary effects, such as onset of postoperative bron-
0302-9530/79/0225/0067/$ 02.20
68
A. Konno and K. Togawa
chial a s t h m a a n d paralysis o f the o c u l a r m u s c l e during o p e r a t i o n h a v e been reported, a n d also l o n g - t e r m results v a r y a c c o r d i n g to different authors. A s r e g a r d s the i n d i c a t i o n o f this o p e r a t i v e t e c h n i q u e , t h e m e c h a n i s m o f the effect o f the o p e r a tion has n o t fully b e e n elucidated. T o e v a l u a t e Vidian n e u r e c t o m y as a t h e r a p y for n a s a l allergy, we e v a l u a t e d p o s t o p e r a t i v e l o n g - t e r m results and p o s t o p e r a t i v e c o m plication, p a r t i c u l a r l y t h e possibility o f d e v e l o p m e n t o f o b s t r u c t i v e v e n t i l a t o r y imp a i r m e n t at p e r i p h e r a l airway, and e l e v a t i o n o f s e r u m total I g E level.
Materials and Methods 1. Subjects are 28 patients who had undergone Vidian neurectomy in our Department because of perennial nasal allergy and had passed 3 - 7 years after the operation. All of them had nasal symptoms which had disturbed their daily lives before the operation and they could not obtain relief by hyposensitization therapy or could not complete hyposensitization for several reasons. Operation was performed by transantral approach according to Goldlng Wood's method (t 961 ) with minor modification. In most cases, because of nasal obstruction remaining after the operation, submucous resection of the nasal septum or submucous turbineetomy was carried out. But for the purpose of observing the effect of Vidian neurectomy alone on nasal obstruction, in nine cases, only Vidian neurectomy was performed regardless of presence or absence of nasal obstruction and they were observed for one year, For the examination, the following inquiry paper was distributed: 1, Degree of satisfaction of patient. 2. Degree of improvement classified by symptoms. 3. Time of recurrence of symptoms and change in symptoms, especially effect of extrinsic and intrinsic factors on recurred symptoms such as pregnancy, season and ingestion of antihistaminic. 4. Degree of improvement in general. 5. Post-operative complaints and complications. Reply could be obtained in all 28 cases, of which 21 patients came to our hospital. Evaluation of the effect of the treatment was made according to the Okuda's criteria (Table 1).
Table 1. Criteria of evaluation of effect of Vidian neurectomy (Okuda, 1974) 1. Degree of each nasal symptom Symptom/degree
+++
++
+
-
Attack of sneezing (daily average times of attack)
More than 10 times
9.9-5.0 times
Less than 4.9-1.0 times
0.9-0 times
Rhinorrhea (dally average times of blowing
More than 10 times
9.9-5.0 times
Less than 4.9-1.0 times
0.9-0 times
Nasal obstruction
Very severe nasal obstruction with oral respiration for fairly long time during a day
Severe nasal obstruction with occasional oral respiration during a day
Nasal obstruction without oral respiration
Degree of disturbance in daily life
Suffer so much as to be unable to work
Middle between (+++) and (+)
Little disturbance for work
nose)
No disturbance
Vidian Neurectomy for Allergic Rhinitis
69
Table 1. (continued)
2. Classification of degree of severity Attack of sneezing Degree of severity Nasal obstruction
+++ ++ + --
+ ++
++
+
Severe Severe Severe Severe
Severe Middle Middle Middle
Severe Middle Light Light
Severe Middle Light None
Severe: severe symptom; Middle: middle symptom; Light: light symptom; None: no symptom 3. Evaluation of effect classified by symptom. Degree of nasal symptoms are compared and based on the difference in grade, effects are evaluated as follows Evaluation of effect
Difference in grade of symptom
Disappearance
(+++) ~ (-)
Marked improvement
( + + + ) ~ (+)
Improvement
(+ + +) -~ (+ +)
(++)-~(§
No change
( + + + ) -~ ( + + + )
(+ +) -0 (+ +)
(+) -, (+)
(++)-~ (+++)
(+)-~(++) (+) -~ (+ + +)
Aggravation
(++) -o ( - )
(+) -o (--)
4. Evaluation of degree of improvement in general. Degree of severity is compared and evaluation is made taking improvement more than two grades for marked improvement, improvement of one grade for improvement, no improvement for no change, and aggravation Degree of improvement
Difference in grade of severity
Marked improvement Improvement No change Aggravation
Severe ~ light, middle ~ no s y m p t o m Severe ~ middle, middle -~ light Severe --,severe, middle ~ middle Middle -~ severe
2. For 21 patients to know presence or absence of obstructive venfilatory impairment at the lower airway, forced vital capacity (FVC), % vital capacity (%VC), forced expiratory volume % (FEV 1.0%), and maximum expiratory flow rate (MEFR) were measured by means of spirometry. V~0 and ~-25 indicating maximum expiratory flow rate at 50% and 25% of vital capacity, respectively, were calculated from the maximum flow volume curve and they were divided by height of body to compare with those of control. V~o and ~'25 are assumed to indicate lesions at respiratory bronchioles and from the pattern of flow volume curve, existence of obstructive ventilatory impairment which can not be seen by FEV 1.0% may be detected (Bass, 1973). Since pre-operative data were not obtained in most of the operated cases for the evaluation of pulmnnary function test results, comparison was made by taking as control 29 male and female patients between 20 and 65 years old who suffered from perennial allergy consisting of house dust allergy and mite allergy without having past anamnesis of bronchial asthma and for whom the same pulmonary tests were carried out. Control subjects were accompanied with allergic symptoms at the time of examination. 3. Variation in total serum IgE level before and after Vidian neurectomy was pursued in 15 cases, which were measured by radio-immunosorbent test using Pharmaeia IgE Kit (Sweden).
70
A. Konno and K. Togawa
Results
1. Change in Symptoms One Year After Vidian Neurectomy In nine cases in which only Vidian neurectomy was carried out, hyperrhinorrhea disappeared in 89% and marked improvement was observed in 11%. On the other hand, the rates of disappearance and marked improvement of sneezing and nasal obstruction were 44% and 33%, respectively (Table 2). Vidian neurectomy exhibited the definite effect on hyperrhinorrhea in all cases. However, effect on nasal obstruction was not enough. Improvement of nasal obstruction as shown in Table 2 resulted not only from reduction of swelling of nasal mucosa but also from decrease of nasal airway resistance due to disappearance of hyperrhinorrhea.
2. Change in Symptoms 3 - 7 Years After Vidian Neurectomy The following long-term results are all in cases where intranasal operation was applied simultaneously for the improvement of nasal obstruction.
a) Degree of Satisfaction of Patients Patients were asked to express degree of their satisfaction by four steps: very satisfactory, satisfactory, comparatively satisfactory, and unsatisfactory. There were 25% very satisfactory cases and 36% satisfactory cases. A total of 61% approximately agreed with disappearance of symptoms or marked effect evaluated by doctors. Seven cases of a comparatively satisfactory group which is, in other words, not a clearly satisfactory group corresponded to those cases evaluated as step one improvement by doctors. The step one improvement by doctoral evaluation does not mean satisfactory cases from the patient's view in many cases. Two patients of four who answered to be dissatisfied, showed improvement of symptoms compared with the pre-operative state but they could not be satisfied with such a degree of improvement, and the other two patients did not notice a change from the pre-operative state because of recurrence.
b) Degree of Improvement Classified by Each Symptom (Table 3) Rhinorrhea. In 57% of 28 cases, the post-operative effect continued and there was little rhinorrhea. In 18% of the cases recurrence of rhinorrhea was observed with daily average times of blowing nose of 1-4.9 times. Also, in 18% of the cases there were 5-9.9 times of blowing nose and in 7% recurrence of rhinorrhea, which needed more than 10 times of blowing nose dally, which was as often as before the operation. The period of recurrence of rhinorrhea was within 1 - 3 years after the operation in most cases (Table 4). The assuredness of neurectomy of secretory nerve can be evaluated by absence of lacrimation according to Schirmer's I and II method.
71
Vidian Neurectomy for Allergic Rhinitis Table 2. Change in nasal symptoms one year after Vidian neurectomy in 9 cases Disappearance
Marked improvement
Improvement
No change
Rhinorrhea
8
I
0
0
Nasal obstruction
2
1
5
1
Sneezing
0
4
4
1
Table 3. Long term results of Vidian neurectomy in 28 cases. Figures in bracket represent number of cases Disappearance
Marked improvement
Improvement
No change
Rhinorrhea
43% (12)
32% (9)
18% (5)
7% (2)
Nasal obstruction
57% (16)
28% (8)
11% (3)
4% (1)
Sneezing
37% (11)
14% (4)
29% (8)
18% (5)
Table 4. Period of recurrence of rhinorrhea in 12 cases Time interval after Vidian neurectomy (years)
Number of cases
0~1
3
~2
3
~3
5
~4
1
Immediately after the operation, lacrimation stopped in all cases. However, one year after the operation, lacrimation of more than 10 m m was observed by Schirmer's I method in about 50% of the cases (Fig. 1). The same tendency was observed b y Schirmer's II method, which suggested reinnervation that occurred relatively early after the operation. However, there was much individual difference in the reinnervation of gland and sometimes, apparent difference was observed between right and left lacrimation even in the same individual.
Nasal Obstruction and Sneezing. D i s a p p e a r a n c e or m a r k e d improvement of nasal obstruction was observed in 85% of the cases. Sneezing disappeared or was markedly improved in 53%.
72
A. Konno and K. Togawa
Lacrimation
3s
e54
20-
i
Io
0 )e.
I
2
3
4
Postoperative Course (Yeors)
Fig. 1. Change of lacrimation after Vidian neurectomy evaluated by Schirmer's I method
3. Change in Symptoms in 12 Cases with Recurrence of Symptoms Every case had shown perennial symptoms with or without seasonal aggravation before the operation. In six cases although the degree of recurred symptoms was mild, it remained perennial. Among them, two patients had symptoms only in dusty place. In the other six cases, perennial symptoms disappeared but seasonal symptoms appeared. One of them suffered from symptoms as severe as those before the operation during the aggravated period and another patient had severe sneezing and nasal obstruction during the period of April and May with no rhinorrhea at all. In both of these two cases the symptoms were readily controlled by ingestion of antihistaminic which was less effective before the operation. In the other four cases, seasonal symptoms were lighter than before the operation. In three cases, symptoms recurred during pregnancy.
4. Degree of Improvement in General (Table 5) When general improvement degree was calculated according to Table 1, every combination of nasal obstruction and sneezing, rhinorrhea and nasal obstruction, rhinorrhea and sneezing, indicated marked improvement of 6 0 - 7 0 % and the rate of improvement was estimated to be 86-90%.
5. Postoperative Complaints and Complications Eleven of 28 cases had some complaints. Four cases of abnormal lacrimation due to malinnervation and 3 cases of paresthesia of the cheek due to antrostomy were most frequent. One of the following complaints, dry sensation in the nose, dry sensation in
73
Vidian Neurectomy for Allergic Rhinitis Table 5. Degree of improvement in general Marked improvement %
Improvement
No change
%
%
Rhinorrhea -- nasal obstruction
71
18
11
Nasal obstruction --sneezing
64
25
11
Rhinorrhea - sneezing
61
25
14
the eye, and rhinorrhea on eating hot food was seen in 3 subjects. Complication of ocular muscle paralysis was seen in no cases. I n one case, bronchial asthma recurred 6 months after the operation. This is 1 of 4 cases with anamnesis of bronchial asthma.
6. Results of Postoperative Pulmonary Function Tests (Fig. 2) N o apparent abnormal values were shown in FVC, % VC, F E V 1.0%, and M E F R measured by spirometry for 21 postoperative cases and 29 control cases. Normal values indicated by gray area in Figure 2 are supplied by Takishima et al. (1972).
J•/sec 3.0 o o
o
Q
~.5
o
o. O
9
o
~
o
%
2.0
9
o
OO
o
0
"~" o
o; O
1.0
o
0.5 o O
30
40
5o
6O
2O
30
40
~
60
20
30
40
50
60
20
~0
40
SO
60
Age Ag~ Age A~e Fig. 2. Results of flow-volumecurve recording in patients with nasal allergy. Each closed circle indicates Vs0/height and V2Jheight in each Vidian neurectomizedsubject. Each open circle indicates those without Vidian neurectomy. Grey area represents normal value with standard deviation
74
A. Konno and K. Togawa IgE level unit/ml
i
Ope.
Preoperative Course
i
2
5
Postoperative Course (Years)
Fig. 3. Variation in serum total IgE level after Vidian neurectomymeasured by radio-imrnunosorbent test Both Ps0/H and V25/H according to the flow volume curve showed change corresponding to age in post-operative group except in 2 subjects. However, in seven of 29 control cases, abnormally low values of P'50/H a n d / / ~ / H were observed, which suggested existence of obstructive ventilatory impairment at the respiratory bronchioles. However, the differences between post-operative group and control group were not statistically significant (or > 0.05), and at least, there was no finding that the obstructive impairment at lower airway developed after Vidian neurectomy.
7. Variation in Serum Total IgE Level (Fig. 3) No apparent variation in measurements due to the operation was observed in 14 of 15 cases. In one case, IgE level was lowered after the operation and it was raised up to the value before operation again after 1 year and 6 months. There was no case with apparent increase in IgE level after the operation.
Discussion
1. On the Mechanism of Effect Obtained by Vidian Neurectomy on Symptoms of Nasal Allergy The degree of improvement differed depending upon symptoms such as rhinorrhea, nasal obstruction, and sneezing. Definite effect was observed for rhinorrhea, but effects for nasal obstruction and sneezing were not enough. Difference in effect of Vidian neurectomy between rhinorrhea and nasal obstruction could be explained by difference in mechanism of onset of rhinorrhea and nasal obstruction. That is, hyperrhinorrhea is produced by reflexive stimulation of the nasal glands via the afferent and efferent nervous pathway through sensory and secretory center, while swell-
Vidian Neurectomy for Allergic Rhinitis
75
ing of nasal mucous membrane is mainly provoked by direct action of chemical mediators on blood vessel (Konno et al., 1979). Effect of Vidian neurectomy is obtained mainly by inhibition of excessive efferent stimulation secondary to excessive afferent stimulation by cutting efferent pathway of reflex arch of nasal secretion. Though there is no change in antigen antibody reaction itself which occurs at nasal mucosa, ceasing of excessive acetylcholine release may affect release of histamine and other chemical mediators from mast cells by the antigen antibody reaction (Kaliner, 1972). This might explain the clinical effects of seeming reduction of hypersensitivity of nasal mucosa and slight or moderate decrease in swelling of nasal mucosa which are observed in some cases after Vidian neurectomy. Hyperrhinorrhea observed in nasal allergy can be also stopped by blocking of cholinergic transmission with intramuscular injection of about 1.5 mg of atropine sulphate. However, when antigen stimulation is given in the state of secretory inhibition by atropine swelling of nasal mucosa and sneezing are enhanced (Konno, 1978). This might be because antigen invades deeply owing to secretory inhibition with increased stimulation of histamine and others on sensory nerve terminal and nasal vasculature. However, after Vidian neurectomy, such phenomenon is rarely observed. There is a difference that after intramuscular injection of atropine afferent stimulation by chemical mediators is enhanced and rather excessive acetylcholine release may occur from efferent nerve terminal. As for the effect of Vidian neureetomy on sneezing, possibility of rise in sensory threshold of the nasal mucosa due to injury on the posterior nasal nerve at the time of Vidian neurectomy should also be considered (Togawa et al., 1971).
2. Long-term Results and Complications of Vidian Neurectomy Considered for a limited period of time, Vidian neurectomy displayed a marked effect for hyperrhinorrhea in 100% of the cases. However, the cases where postoperative effect continued after a lapse of 3--7 years were only 53% and in 47% of the cases rhinorrhea recurred although its degree varied. Several changes in symptoms with reinnervation were observed. Antihistaminics, which were ineffective before the operation, became very effective for the recurred symptoms and some cases with perennial symptoms showed recurred symptoms only at the change of season or recurred symptoms were observed only during pregnancy. Recurrence of rhinorrhea and lacrimation is considered to be due to regeneration of nerve fiber constituting Vidian nerve and considering from lacrimation estimated by Schirmer's test, regeneration of nerve started relatively early, within one year after the operation. It is also considered possible that recurrence of symptoms is provoked by reinnervation of the nasal glands owing to cholinergic fibers other than Vidian nerve which regulates nasal mucosa. However, considering the fairly easy regeneration of secretory nerve as is seen in Frey's syndrome after parotidectomy, there is room for improvement to prevent regeneration of nerve in the present operative technique which only cauterizes the cut nerve terminal. The most frequent postoperative complaints were buccal paresthesia and abnormal lacrimation, although both of which were minor complaints. The matter which we most worried about during the process of Vidian neurectomy was that the operative removal of rhinorrhea, nasal obstruction and sneezing might facilitate aspiration of antigen into lower airway in cases with such
76
A. Konno and K. Togawa
systemic diathesis as atopic allergy, causing enhancement of hypersensitivity at lower airway mucosa and onset of bronchial asthma. The combined rates of bronchial asthma in nasal allergy are high and in cases with nasal allergy in which symptoms of bronchial asthma are not apparent clinically, existence of obstructive impairment in the area of respiratory bronchioles is observed at a high rate when examined by recording of flow volume curves (Grossman, 1975). In one case out of 37 cases to which we have so far performed Vidian neurectomy for nasal allergy, bronchial asthma which had not been observed for several years recurred 6 months after the operation. It is not clear whether or not Vidian neurectomy was the direct cause of onset of bronchial asthma in our case, but from results of pulmonary function test in our other post-operative cases there were no findings to show that ventilatory impairment in the lower airway developed after the operation. On the contrary, Hiranandani (1976) and Su (1976) carried out Vidian neurectomy actively for cases of nasal allergy complicated with bronchial asthma and reported effective results for bronchial asthma, however, to our regret, there is no report on pulmonary function tests before and after the operation. Another possibility which worried us was that antigen antibody reaction might be enhanced on nasal mucosa in the state where protective reflexes of rhinorrhea, nasal obstruction and sneezing were attenuated or disappeared by the operation. Specific IgE level could not be measured by radio allergosorbent test (RAST) in the present study, but total serum IgE level showed no apparent tendency to increase after the operation. There was a case in which IgE level decreased apparently after the operation and then rose up to the level before the operation after 1 year and 6 months, but in order to interprete this, more cases should be examined. Paralysis of ocular muscle after Vidian neurectomy has often been reported, but in our 138 cases for which we performed Vidian neurectomy so far, we have had no experience of these complications. Complication is caused by gliding of electric current to the surrounding nervous tissue during cauterization of the nerve cut terminal using electric current (Nomura et al., 1977), and if diathermy is used according to the original method there is no risk of gliding of electric current.
Conclusion The basic treatment of nasal allergy today consists of hyposensitization therapy, but it takes a long time for this treatment and the effect comes slowly. There are cases where difinite antigen is unknown. The greatest merit of Vidian neurectomy is rapid effect and the fact that operation only once can remove the symptoms in high percentage of cases without necessity of after-treatment. Effect of Vidian neurectomy is obtained mainly by cutting efferent nervous pathway. However, by means of the present operation technique, there is a great possibility that recurrence of symptoms due to regeneration of the nerve is induced. There is certainly room for improvement of operative technique to inhibit regeneration of nerve, e.g., by performing bony closure of the Vidian canal with bone grafting. However, merit of operative therapy is still considered large, if the indication is strictly selected for those perennial cases in which daily life is disturbed and hyposensitization therapy results in no expected effect.
Vidian Neurectomy for Allergic Rhinitis
77
References Bass, H.: The flow volume loop; normal standards and abnormalities in chronic obstructive pulmonary disease. Chest 63, 171 (1973) Golding Wood, P. H.: Observation on petrosal and Vidian neurectomy in chronic vasomotor rhinitis. J. Laryngol. 75, 232 (1961) Golding Wood, P. H.: Pathology and surgery of chronic vasomotor rhinitis. J. Laryngol. 76, 969 (1962) Grossman, J.: Small airway obstruction in allergic rhinitis. J. Allergy Clin. Immunol. 55, 49 (1975) Hiranandani, L. H.: Clinicopathological study of allergic rhinitis and the place of Vidian neurectomy. Proceedings International Symposium "Infection and Allergy of the Nose and Paranasal Sinuses", pp. 340--343. Tokyo: SCIMED Publications Inc. 1976 Kaliner, M. D., Orange, P. H., Laraia, J. P.: Cholinergic enhancement of the immunologic release of histamine and slow-reacting substance of anaphylaxis (SRS-A) from human lung tissue. J. Allergy Clin. Immunol. 49, 88 (1972) Konno, A., Togawa, K.: Role of the Vidian nerve in nasal allergy. Ann. Otol. Rhinol. Laryngol. 88, 258 (1979) Konno, A. (unpublished data) Nomura, Y., Matsuura, T.: Distribution and clinical significance of the autonomic nervous system in the human nasal mucosa. Acta Otolaryngol. 73, 493 (1972) Nomura, Y., Ichimura, K.: Transantral subperiosteal Vidian neurectomy, a technique and case followups. Proceedings International Symposium "Infection and Allergy of the Nose and Paranasal Sinuses", pp. 335--337. Tokyo: SCIMED Publications Inc. 1976 Okuda, M,: Fundamental and clinical studies on nasal allergy. Otologia (Fukuoka) 20, 297 (1974) Su, W. Y.: Clinical study of Vidian neurectomy in perennial allergic rhinitis. Proceedings International Symposium "Infection and Allergy of the Nose and Paranasal Sinuses", pp. 332-334. Tokyo: SCIMED Publications Inc. 1976 Takahashi, R., Tsutsumi, M.: Vidian neurectomy. Otorhinolaryngology (Tokyo) 13, 719 (1970) Takishima, T., Sasaki, T., Takahashi, K., Sasaki, H., Nakamura, T.: Direct-writing recorder of the flow-volume curve and its clinical application. Chest 61, 262 (1972) Togawa, K., Miyashita, H., Fujita, Y., Shimada, T., Naito, J.: Vidian neurectomy for allergic rhinitis. Pract. Otologica Kyoto [Suppl.] 64, 1223 (1971) Received January 1979/March 22, 1979
Oto-Rhino-Laryngology
Arch. Otorhinolaryngol. 225, 67--77 (1979)
9 Springer-Verlag 1979
Vidian Neurectomy for Allergic Rhinitis Evaluation of Long-term Results and Some Problems Concerning Operative Therapy Akiyoshi Konno and Kiyoshi Togawa Department of Otorhinolaryngology,Akita University, School of Medicine, 1-1-1 Hondo, Akita City, Akita Pref., Japan
Summary. Vidian neurectomy was performed in 28 patients with perennial nasal allergy and changes in symptoms and complications 3 - 7 years after the operation were examined in order to evaluate the effect and limitation of the operative therapy on nasal allergy. Vidian neurectomy could completely stop hyperrhinorrhea in all cases for a limited period of time. In 43% cases, however, recurrence of rhinorrhea was observed. As for nasal obstruction, disappearance of the symptom or marked improvement was noted in only 33% of the cases and in many eases, intranasal operation was also required for improvement of nasal obstruction. Disappearance of nasal obstruction and marked improvement when intranasal operation was also applied was noted in 85% of cases. If the grade one improvement was included, general improvement of the symptoms of nasal allergy lasted in 8 6 - 9 0 % of the cases. Effect of operative removal of sneezing, nasal obstruction, and rhinorrhea which are considered to be defensive reflex, on lower airway or whole body was examined by pulmonary function tests and measurement of serum total IgE level. There were no postoperative tendency to development of obstructive ventilatory impairment at the lower airway or to increase in serum total IgE level. There is room to improve the operative technique to inhibit reinnervation, however, the merit of Vidian neurectomy is large for selected patients with perennial nasal allergy, because when combined with intranasal operation to relieve nasal obstruction it can remove the symptoms in high percentage of cases by a single performance. Key words: Nasal allergy - Vidian neurectomy
Since Golding Wood (1961) reported Vidian neurectomy as an operative therapy for vasomotor rhinitis, this method has been tried in many hospitals for vasomotor rhinitis and dramatic clinical effects have been reported. Recently, the indication has been widened and this method has been carried out also for nasal allergy (Noruma et al., 1972; Takahashi et al., 1970; Togawa et al., 1971). However, with spread of this operative technique, several secondary effects, such as onset of postoperative bron-
0302-9530/79/0225/0067/$ 02.20
68
A. Konno and K. Togawa
chial a s t h m a a n d paralysis o f the o c u l a r m u s c l e during o p e r a t i o n h a v e been reported, a n d also l o n g - t e r m results v a r y a c c o r d i n g to different authors. A s r e g a r d s the i n d i c a t i o n o f this o p e r a t i v e t e c h n i q u e , t h e m e c h a n i s m o f the effect o f the o p e r a tion has n o t fully b e e n elucidated. T o e v a l u a t e Vidian n e u r e c t o m y as a t h e r a p y for n a s a l allergy, we e v a l u a t e d p o s t o p e r a t i v e l o n g - t e r m results and p o s t o p e r a t i v e c o m plication, p a r t i c u l a r l y t h e possibility o f d e v e l o p m e n t o f o b s t r u c t i v e v e n t i l a t o r y imp a i r m e n t at p e r i p h e r a l airway, and e l e v a t i o n o f s e r u m total I g E level.
Materials and Methods 1. Subjects are 28 patients who had undergone Vidian neurectomy in our Department because of perennial nasal allergy and had passed 3 - 7 years after the operation. All of them had nasal symptoms which had disturbed their daily lives before the operation and they could not obtain relief by hyposensitization therapy or could not complete hyposensitization for several reasons. Operation was performed by transantral approach according to Goldlng Wood's method (t 961 ) with minor modification. In most cases, because of nasal obstruction remaining after the operation, submucous resection of the nasal septum or submucous turbineetomy was carried out. But for the purpose of observing the effect of Vidian neurectomy alone on nasal obstruction, in nine cases, only Vidian neurectomy was performed regardless of presence or absence of nasal obstruction and they were observed for one year, For the examination, the following inquiry paper was distributed: 1, Degree of satisfaction of patient. 2. Degree of improvement classified by symptoms. 3. Time of recurrence of symptoms and change in symptoms, especially effect of extrinsic and intrinsic factors on recurred symptoms such as pregnancy, season and ingestion of antihistaminic. 4. Degree of improvement in general. 5. Post-operative complaints and complications. Reply could be obtained in all 28 cases, of which 21 patients came to our hospital. Evaluation of the effect of the treatment was made according to the Okuda's criteria (Table 1).
Table 1. Criteria of evaluation of effect of Vidian neurectomy (Okuda, 1974) 1. Degree of each nasal symptom Symptom/degree
+++
++
+
-
Attack of sneezing (daily average times of attack)
More than 10 times
9.9-5.0 times
Less than 4.9-1.0 times
0.9-0 times
Rhinorrhea (dally average times of blowing
More than 10 times
9.9-5.0 times
Less than 4.9-1.0 times
0.9-0 times
Nasal obstruction
Very severe nasal obstruction with oral respiration for fairly long time during a day
Severe nasal obstruction with occasional oral respiration during a day
Nasal obstruction without oral respiration
Degree of disturbance in daily life
Suffer so much as to be unable to work
Middle between (+++) and (+)
Little disturbance for work
nose)
No disturbance
Vidian Neurectomy for Allergic Rhinitis
69
Table 1. (continued)
2. Classification of degree of severity Attack of sneezing Degree of severity Nasal obstruction
+++ ++ + --
+ ++
++
+
Severe Severe Severe Severe
Severe Middle Middle Middle
Severe Middle Light Light
Severe Middle Light None
Severe: severe symptom; Middle: middle symptom; Light: light symptom; None: no symptom 3. Evaluation of effect classified by symptom. Degree of nasal symptoms are compared and based on the difference in grade, effects are evaluated as follows Evaluation of effect
Difference in grade of symptom
Disappearance
(+++) ~ (-)
Marked improvement
( + + + ) ~ (+)
Improvement
(+ + +) -~ (+ +)
(++)-~(§
No change
( + + + ) -~ ( + + + )
(+ +) -0 (+ +)
(+) -, (+)
(++)-~ (+++)
(+)-~(++) (+) -~ (+ + +)
Aggravation
(++) -o ( - )
(+) -o (--)
4. Evaluation of degree of improvement in general. Degree of severity is compared and evaluation is made taking improvement more than two grades for marked improvement, improvement of one grade for improvement, no improvement for no change, and aggravation Degree of improvement
Difference in grade of severity
Marked improvement Improvement No change Aggravation
Severe ~ light, middle ~ no s y m p t o m Severe ~ middle, middle -~ light Severe --,severe, middle ~ middle Middle -~ severe
2. For 21 patients to know presence or absence of obstructive venfilatory impairment at the lower airway, forced vital capacity (FVC), % vital capacity (%VC), forced expiratory volume % (FEV 1.0%), and maximum expiratory flow rate (MEFR) were measured by means of spirometry. V~0 and ~-25 indicating maximum expiratory flow rate at 50% and 25% of vital capacity, respectively, were calculated from the maximum flow volume curve and they were divided by height of body to compare with those of control. V~o and ~'25 are assumed to indicate lesions at respiratory bronchioles and from the pattern of flow volume curve, existence of obstructive ventilatory impairment which can not be seen by FEV 1.0% may be detected (Bass, 1973). Since pre-operative data were not obtained in most of the operated cases for the evaluation of pulmnnary function test results, comparison was made by taking as control 29 male and female patients between 20 and 65 years old who suffered from perennial allergy consisting of house dust allergy and mite allergy without having past anamnesis of bronchial asthma and for whom the same pulmonary tests were carried out. Control subjects were accompanied with allergic symptoms at the time of examination. 3. Variation in total serum IgE level before and after Vidian neurectomy was pursued in 15 cases, which were measured by radio-immunosorbent test using Pharmaeia IgE Kit (Sweden).
70
A. Konno and K. Togawa
Results
1. Change in Symptoms One Year After Vidian Neurectomy In nine cases in which only Vidian neurectomy was carried out, hyperrhinorrhea disappeared in 89% and marked improvement was observed in 11%. On the other hand, the rates of disappearance and marked improvement of sneezing and nasal obstruction were 44% and 33%, respectively (Table 2). Vidian neurectomy exhibited the definite effect on hyperrhinorrhea in all cases. However, effect on nasal obstruction was not enough. Improvement of nasal obstruction as shown in Table 2 resulted not only from reduction of swelling of nasal mucosa but also from decrease of nasal airway resistance due to disappearance of hyperrhinorrhea.
2. Change in Symptoms 3 - 7 Years After Vidian Neurectomy The following long-term results are all in cases where intranasal operation was applied simultaneously for the improvement of nasal obstruction.
a) Degree of Satisfaction of Patients Patients were asked to express degree of their satisfaction by four steps: very satisfactory, satisfactory, comparatively satisfactory, and unsatisfactory. There were 25% very satisfactory cases and 36% satisfactory cases. A total of 61% approximately agreed with disappearance of symptoms or marked effect evaluated by doctors. Seven cases of a comparatively satisfactory group which is, in other words, not a clearly satisfactory group corresponded to those cases evaluated as step one improvement by doctors. The step one improvement by doctoral evaluation does not mean satisfactory cases from the patient's view in many cases. Two patients of four who answered to be dissatisfied, showed improvement of symptoms compared with the pre-operative state but they could not be satisfied with such a degree of improvement, and the other two patients did not notice a change from the pre-operative state because of recurrence.
b) Degree of Improvement Classified by Each Symptom (Table 3) Rhinorrhea. In 57% of 28 cases, the post-operative effect continued and there was little rhinorrhea. In 18% of the cases recurrence of rhinorrhea was observed with daily average times of blowing nose of 1-4.9 times. Also, in 18% of the cases there were 5-9.9 times of blowing nose and in 7% recurrence of rhinorrhea, which needed more than 10 times of blowing nose dally, which was as often as before the operation. The period of recurrence of rhinorrhea was within 1 - 3 years after the operation in most cases (Table 4). The assuredness of neurectomy of secretory nerve can be evaluated by absence of lacrimation according to Schirmer's I and II method.
71
Vidian Neurectomy for Allergic Rhinitis Table 2. Change in nasal symptoms one year after Vidian neurectomy in 9 cases Disappearance
Marked improvement
Improvement
No change
Rhinorrhea
8
I
0
0
Nasal obstruction
2
1
5
1
Sneezing
0
4
4
1
Table 3. Long term results of Vidian neurectomy in 28 cases. Figures in bracket represent number of cases Disappearance
Marked improvement
Improvement
No change
Rhinorrhea
43% (12)
32% (9)
18% (5)
7% (2)
Nasal obstruction
57% (16)
28% (8)
11% (3)
4% (1)
Sneezing
37% (11)
14% (4)
29% (8)
18% (5)
Table 4. Period of recurrence of rhinorrhea in 12 cases Time interval after Vidian neurectomy (years)
Number of cases
0~1
3
~2
3
~3
5
~4
1
Immediately after the operation, lacrimation stopped in all cases. However, one year after the operation, lacrimation of more than 10 m m was observed by Schirmer's I method in about 50% of the cases (Fig. 1). The same tendency was observed b y Schirmer's II method, which suggested reinnervation that occurred relatively early after the operation. However, there was much individual difference in the reinnervation of gland and sometimes, apparent difference was observed between right and left lacrimation even in the same individual.
Nasal Obstruction and Sneezing. D i s a p p e a r a n c e or m a r k e d improvement of nasal obstruction was observed in 85% of the cases. Sneezing disappeared or was markedly improved in 53%.
72
A. Konno and K. Togawa
Lacrimation
3s
e54
20-
i
Io
0 )e.
I
2
3
4
Postoperative Course (Yeors)
Fig. 1. Change of lacrimation after Vidian neurectomy evaluated by Schirmer's I method
3. Change in Symptoms in 12 Cases with Recurrence of Symptoms Every case had shown perennial symptoms with or without seasonal aggravation before the operation. In six cases although the degree of recurred symptoms was mild, it remained perennial. Among them, two patients had symptoms only in dusty place. In the other six cases, perennial symptoms disappeared but seasonal symptoms appeared. One of them suffered from symptoms as severe as those before the operation during the aggravated period and another patient had severe sneezing and nasal obstruction during the period of April and May with no rhinorrhea at all. In both of these two cases the symptoms were readily controlled by ingestion of antihistaminic which was less effective before the operation. In the other four cases, seasonal symptoms were lighter than before the operation. In three cases, symptoms recurred during pregnancy.
4. Degree of Improvement in General (Table 5) When general improvement degree was calculated according to Table 1, every combination of nasal obstruction and sneezing, rhinorrhea and nasal obstruction, rhinorrhea and sneezing, indicated marked improvement of 6 0 - 7 0 % and the rate of improvement was estimated to be 86-90%.
5. Postoperative Complaints and Complications Eleven of 28 cases had some complaints. Four cases of abnormal lacrimation due to malinnervation and 3 cases of paresthesia of the cheek due to antrostomy were most frequent. One of the following complaints, dry sensation in the nose, dry sensation in
73
Vidian Neurectomy for Allergic Rhinitis Table 5. Degree of improvement in general Marked improvement %
Improvement
No change
%
%
Rhinorrhea -- nasal obstruction
71
18
11
Nasal obstruction --sneezing
64
25
11
Rhinorrhea - sneezing
61
25
14
the eye, and rhinorrhea on eating hot food was seen in 3 subjects. Complication of ocular muscle paralysis was seen in no cases. I n one case, bronchial asthma recurred 6 months after the operation. This is 1 of 4 cases with anamnesis of bronchial asthma.
6. Results of Postoperative Pulmonary Function Tests (Fig. 2) N o apparent abnormal values were shown in FVC, % VC, F E V 1.0%, and M E F R measured by spirometry for 21 postoperative cases and 29 control cases. Normal values indicated by gray area in Figure 2 are supplied by Takishima et al. (1972).
J•/sec 3.0 o o
o
Q
~.5
o
o. O
9
o
~
o
%
2.0
9
o
OO
o
0
"~" o
o; O
1.0
o
0.5 o O
30
40
5o
6O
2O
30
40
~
60
20
30
40
50
60
20
~0
40
SO
60
Age Ag~ Age A~e Fig. 2. Results of flow-volumecurve recording in patients with nasal allergy. Each closed circle indicates Vs0/height and V2Jheight in each Vidian neurectomizedsubject. Each open circle indicates those without Vidian neurectomy. Grey area represents normal value with standard deviation
74
A. Konno and K. Togawa IgE level unit/ml
i
Ope.
Preoperative Course
i
2
5
Postoperative Course (Years)
Fig. 3. Variation in serum total IgE level after Vidian neurectomymeasured by radio-imrnunosorbent test Both Ps0/H and V25/H according to the flow volume curve showed change corresponding to age in post-operative group except in 2 subjects. However, in seven of 29 control cases, abnormally low values of P'50/H a n d / / ~ / H were observed, which suggested existence of obstructive ventilatory impairment at the respiratory bronchioles. However, the differences between post-operative group and control group were not statistically significant (or > 0.05), and at least, there was no finding that the obstructive impairment at lower airway developed after Vidian neurectomy.
7. Variation in Serum Total IgE Level (Fig. 3) No apparent variation in measurements due to the operation was observed in 14 of 15 cases. In one case, IgE level was lowered after the operation and it was raised up to the value before operation again after 1 year and 6 months. There was no case with apparent increase in IgE level after the operation.
Discussion
1. On the Mechanism of Effect Obtained by Vidian Neurectomy on Symptoms of Nasal Allergy The degree of improvement differed depending upon symptoms such as rhinorrhea, nasal obstruction, and sneezing. Definite effect was observed for rhinorrhea, but effects for nasal obstruction and sneezing were not enough. Difference in effect of Vidian neurectomy between rhinorrhea and nasal obstruction could be explained by difference in mechanism of onset of rhinorrhea and nasal obstruction. That is, hyperrhinorrhea is produced by reflexive stimulation of the nasal glands via the afferent and efferent nervous pathway through sensory and secretory center, while swell-
Vidian Neurectomy for Allergic Rhinitis
75
ing of nasal mucous membrane is mainly provoked by direct action of chemical mediators on blood vessel (Konno et al., 1979). Effect of Vidian neurectomy is obtained mainly by inhibition of excessive efferent stimulation secondary to excessive afferent stimulation by cutting efferent pathway of reflex arch of nasal secretion. Though there is no change in antigen antibody reaction itself which occurs at nasal mucosa, ceasing of excessive acetylcholine release may affect release of histamine and other chemical mediators from mast cells by the antigen antibody reaction (Kaliner, 1972). This might explain the clinical effects of seeming reduction of hypersensitivity of nasal mucosa and slight or moderate decrease in swelling of nasal mucosa which are observed in some cases after Vidian neurectomy. Hyperrhinorrhea observed in nasal allergy can be also stopped by blocking of cholinergic transmission with intramuscular injection of about 1.5 mg of atropine sulphate. However, when antigen stimulation is given in the state of secretory inhibition by atropine swelling of nasal mucosa and sneezing are enhanced (Konno, 1978). This might be because antigen invades deeply owing to secretory inhibition with increased stimulation of histamine and others on sensory nerve terminal and nasal vasculature. However, after Vidian neurectomy, such phenomenon is rarely observed. There is a difference that after intramuscular injection of atropine afferent stimulation by chemical mediators is enhanced and rather excessive acetylcholine release may occur from efferent nerve terminal. As for the effect of Vidian neureetomy on sneezing, possibility of rise in sensory threshold of the nasal mucosa due to injury on the posterior nasal nerve at the time of Vidian neurectomy should also be considered (Togawa et al., 1971).
2. Long-term Results and Complications of Vidian Neurectomy Considered for a limited period of time, Vidian neurectomy displayed a marked effect for hyperrhinorrhea in 100% of the cases. However, the cases where postoperative effect continued after a lapse of 3--7 years were only 53% and in 47% of the cases rhinorrhea recurred although its degree varied. Several changes in symptoms with reinnervation were observed. Antihistaminics, which were ineffective before the operation, became very effective for the recurred symptoms and some cases with perennial symptoms showed recurred symptoms only at the change of season or recurred symptoms were observed only during pregnancy. Recurrence of rhinorrhea and lacrimation is considered to be due to regeneration of nerve fiber constituting Vidian nerve and considering from lacrimation estimated by Schirmer's test, regeneration of nerve started relatively early, within one year after the operation. It is also considered possible that recurrence of symptoms is provoked by reinnervation of the nasal glands owing to cholinergic fibers other than Vidian nerve which regulates nasal mucosa. However, considering the fairly easy regeneration of secretory nerve as is seen in Frey's syndrome after parotidectomy, there is room for improvement to prevent regeneration of nerve in the present operative technique which only cauterizes the cut nerve terminal. The most frequent postoperative complaints were buccal paresthesia and abnormal lacrimation, although both of which were minor complaints. The matter which we most worried about during the process of Vidian neurectomy was that the operative removal of rhinorrhea, nasal obstruction and sneezing might facilitate aspiration of antigen into lower airway in cases with such
76
A. Konno and K. Togawa
systemic diathesis as atopic allergy, causing enhancement of hypersensitivity at lower airway mucosa and onset of bronchial asthma. The combined rates of bronchial asthma in nasal allergy are high and in cases with nasal allergy in which symptoms of bronchial asthma are not apparent clinically, existence of obstructive impairment in the area of respiratory bronchioles is observed at a high rate when examined by recording of flow volume curves (Grossman, 1975). In one case out of 37 cases to which we have so far performed Vidian neurectomy for nasal allergy, bronchial asthma which had not been observed for several years recurred 6 months after the operation. It is not clear whether or not Vidian neurectomy was the direct cause of onset of bronchial asthma in our case, but from results of pulmonary function test in our other post-operative cases there were no findings to show that ventilatory impairment in the lower airway developed after the operation. On the contrary, Hiranandani (1976) and Su (1976) carried out Vidian neurectomy actively for cases of nasal allergy complicated with bronchial asthma and reported effective results for bronchial asthma, however, to our regret, there is no report on pulmonary function tests before and after the operation. Another possibility which worried us was that antigen antibody reaction might be enhanced on nasal mucosa in the state where protective reflexes of rhinorrhea, nasal obstruction and sneezing were attenuated or disappeared by the operation. Specific IgE level could not be measured by radio allergosorbent test (RAST) in the present study, but total serum IgE level showed no apparent tendency to increase after the operation. There was a case in which IgE level decreased apparently after the operation and then rose up to the level before the operation after 1 year and 6 months, but in order to interprete this, more cases should be examined. Paralysis of ocular muscle after Vidian neurectomy has often been reported, but in our 138 cases for which we performed Vidian neurectomy so far, we have had no experience of these complications. Complication is caused by gliding of electric current to the surrounding nervous tissue during cauterization of the nerve cut terminal using electric current (Nomura et al., 1977), and if diathermy is used according to the original method there is no risk of gliding of electric current.
Conclusion The basic treatment of nasal allergy today consists of hyposensitization therapy, but it takes a long time for this treatment and the effect comes slowly. There are cases where difinite antigen is unknown. The greatest merit of Vidian neurectomy is rapid effect and the fact that operation only once can remove the symptoms in high percentage of cases without necessity of after-treatment. Effect of Vidian neurectomy is obtained mainly by cutting efferent nervous pathway. However, by means of the present operation technique, there is a great possibility that recurrence of symptoms due to regeneration of the nerve is induced. There is certainly room for improvement of operative technique to inhibit regeneration of nerve, e.g., by performing bony closure of the Vidian canal with bone grafting. However, merit of operative therapy is still considered large, if the indication is strictly selected for those perennial cases in which daily life is disturbed and hyposensitization therapy results in no expected effect.
Vidian Neurectomy for Allergic Rhinitis
77
References Bass, H.: The flow volume loop; normal standards and abnormalities in chronic obstructive pulmonary disease. Chest 63, 171 (1973) Golding Wood, P. H.: Observation on petrosal and Vidian neurectomy in chronic vasomotor rhinitis. J. Laryngol. 75, 232 (1961) Golding Wood, P. H.: Pathology and surgery of chronic vasomotor rhinitis. J. Laryngol. 76, 969 (1962) Grossman, J.: Small airway obstruction in allergic rhinitis. J. Allergy Clin. Immunol. 55, 49 (1975) Hiranandani, L. H.: Clinicopathological study of allergic rhinitis and the place of Vidian neurectomy. Proceedings International Symposium "Infection and Allergy of the Nose and Paranasal Sinuses", pp. 340--343. Tokyo: SCIMED Publications Inc. 1976 Kaliner, M. D., Orange, P. H., Laraia, J. P.: Cholinergic enhancement of the immunologic release of histamine and slow-reacting substance of anaphylaxis (SRS-A) from human lung tissue. J. Allergy Clin. Immunol. 49, 88 (1972) Konno, A., Togawa, K.: Role of the Vidian nerve in nasal allergy. Ann. Otol. Rhinol. Laryngol. 88, 258 (1979) Konno, A. (unpublished data) Nomura, Y., Matsuura, T.: Distribution and clinical significance of the autonomic nervous system in the human nasal mucosa. Acta Otolaryngol. 73, 493 (1972) Nomura, Y., Ichimura, K.: Transantral subperiosteal Vidian neurectomy, a technique and case followups. Proceedings International Symposium "Infection and Allergy of the Nose and Paranasal Sinuses", pp. 335--337. Tokyo: SCIMED Publications Inc. 1976 Okuda, M,: Fundamental and clinical studies on nasal allergy. Otologia (Fukuoka) 20, 297 (1974) Su, W. Y.: Clinical study of Vidian neurectomy in perennial allergic rhinitis. Proceedings International Symposium "Infection and Allergy of the Nose and Paranasal Sinuses", pp. 332-334. Tokyo: SCIMED Publications Inc. 1976 Takahashi, R., Tsutsumi, M.: Vidian neurectomy. Otorhinolaryngology (Tokyo) 13, 719 (1970) Takishima, T., Sasaki, T., Takahashi, K., Sasaki, H., Nakamura, T.: Direct-writing recorder of the flow-volume curve and its clinical application. Chest 61, 262 (1972) Togawa, K., Miyashita, H., Fujita, Y., Shimada, T., Naito, J.: Vidian neurectomy for allergic rhinitis. Pract. Otologica Kyoto [Suppl.] 64, 1223 (1971) Received January 1979/March 22, 1979
