Position Statement: PNN Ablation for the Treatment of Chronic Rhinitis

Chronic rhinitis is a common condition that affects approximately 60 million Americans and presents with symptoms that include nasal congestion, rhinorrhea/postnasal drip, nasal pruritus, and sneezing^1,2. Although medications such as intranasal saline, intranasal corticosteroids, intranasal anticholinergics, oral/topical antihistamines, and/or oral/topical decongestants may be utilized as single or combination first-line therapies, many patients do not receive adequate symptomatic improvement from medical management alone.

Reducing parasympathetic innervation to the nasal cavity can improve these chronic rhinitis symptoms.  However, because of the morbidity of a vidian neurectomy^3,4, the traditional surgical technique, recent interventions have focused on ablating the distal branches of the nasal parasympathetic system, called the posterior nasal nerves (PNN).  These nerves are accessed and ablated endonasally without the associated risks of a vidian neurectomy.

Posterior nasal nerve neurolysis techniques that utilize radiofrequency or cryotherapy are used to disrupt the PNN in the posterior lateral nasal cavity.  Multicenter, patient-blinded, sham-controlled RCTs have been performed for radiofrequency ablation^5,6 and cryoablation⁷ and have demonstrated clinical benefit for nasal symptoms. For both methods, validated quality of life surveys demonstrated statistically significant, durable improvement with treatment^8-10, with clinically significant therapeutic effect^{11, 12}.

Based on these safety and efficacy data, the AAO endorses the use of PNN ablation for the treatment of refractory chronic rhinitis. We do not consider these treatments to be investigational  or experimental  and consider the following Selection Criteria appropriate for Posterior Nasal Nerve Ablation:

1. Moderate to severe symptoms of rhinitis that have lasted more than 12 weeks
   a. Etiologies include but are not limited to allergic, non-allergic, vasomotor and gustatory rhinitis
   b. Patient reported moderate to severe symptoms must include at least 1 of:
   i. Nasal congestion or stuffiness
   ii. Nasal blockage or obstruction
   iii. Trouble breathing through the nose
   iv. Anterior rhinorrhea
   v. Posterior rhinorrhea (i.e. postnasal drainage)
2. Failure, contraindication or intolerance to medical therapy that include at least 2 out of the 3 of intranasal corticosteroids, intranasal antihistamines OR anticholinergic sprays
   a. Failure is defined as persistent severe to moderate symptoms despite 4 weeks of 2 out of 3 of these therapies (do not need to be administered concurrently). 
3. Co-morbid disease contributing to symptoms should be ruled out and/or be under appropriate control (i.e. CRS with or without polyposis, inhalant allergy, etc.).

Approved February 2023
Updated May 2026

References

1. Bernstein, J. A. Allergic and mixed rhinitis: Epidemiology and natural history. Allergy Asthma Proc 31, 365-369, doi:10.2500/aap.2010.31.3380 (2010).
2. Settipane, R. A. & Charnock, D. R. Epidemiology of rhinitis: allergic and nonallergic. Clin Allergy Immunol 19, 23-34 (2007).
3. Robinson, S. R. & Wormald, P. J. Endoscopic vidian neurectomy. Am J Rhinol 20, 197-202 (2006).
4. Konno, A. Historical, pathophysiological, and therapeutic aspects of vidian neurectomy. Curr Allergy Asthma Rep 10, 105-112, doi:10.1007/s11882-010-0093-3 (2010).
5. Takashima, M. et al. Temperature-controlled radiofrequency neurolysis for treatment of chronic rhinitis: 12-month outcomes after treatment in a randomized controlled trial. Int Forum Allergy Rhinol, doi:10.1002/alr.23047 (2022).
6. Stolovitzky, J. P. et al. Effect of Radiofrequency Neurolysis on the Symptoms of Chronic Rhinitis: A Randomized Controlled Trial. OTO Open 5, 2473974X211041124, doi:10.1177/2473974X211041124 (2021).
7. Del Signore, A. G. et al. Cryotherapy for treatment of chronic rhinitis: 3-month outcomes of a randomized, sham-controlled trial. Int Forum Allergy Rhinol 12, 51-61, doi:10.1002/alr.22868 (2022).
8. Ow, R. A., O’Malley, E. M., Han, J. K., Lam, K. K. & Yen, D. M. Cryosurgical Ablation for Treatment of Rhinitis: Two-Year Results of a Prospective Multicenter Study. Laryngoscope 131, 1952-1957, doi:10.1002/lary.29453 (2021).
9. Chang, M. T., Song, S. & Hwang, P. H. Cryosurgical ablation for treatment of rhinitis: A prospective multicenter study. Laryngoscope 130, 1877-1884, doi:10.1002/lary.28301 (2020).
10. Lee, J. T. et al. Clinical and Quality of Life Outcomes Following Temperature-Controlled Radiofrequency Neurolysis of the Posterior Nasal Nerve (RhinAer) for Treatment of Chronic Rhinitis. Am J Rhinol Allergy, 19458924221109987, doi:10.1177/19458924221109987 (2022).
11. Ehmer, D. et al. Long-term Outcomes Following Temperature-Controlled Radiofrequency Neurolysis for the Treatment of Chronic Rhinitis. Allergy Rhinol (Providence) 13, 21526575221096045, doi:10.1177/21526575221096045 (2022).
12. Gerka Stuyt, J. A., Luk, L., Keschner, D. & Garg, R. Evaluation of In-Office Cryoablation of Posterior Nasal Nerves for the Treatment of Rhinitis. Allergy Rhinol (Providence) 12, 2152656720988565, doi:10.1177/2152656720988565 (2021).
13. Ehmer, D. et al. Temperature-Controlled Radiofrequency Neurolysis for the Treatment of Rhinitis. Am J Rhinol Allergy 36, 149-156, doi:10.1177/19458924211033400 (2022).
14. Kompelli, A. R., Janz, T. A., Rowan, N. R., Nguyen, S. A. & Soler, Z. M. Cryotherapy for the Treatment of Chronic Rhinitis: A Qualitative Systematic Review. Am J Rhinol Allergy 32, 491-501, doi:10.1177/1945892418800879 (2018).
15. Davis GE, Ow RA, Yen DM, O’Malley EM, Del Signore AG. Clinical Outcomes After Innovative Multipoint Impedance-Controlled Radiofrequency Ablation of the Posterior Nasal Nerve for Treatment of Chronic Rhinitis. Ear Nose Throat J. 2024 Sep 24:1455613241285134. doi: 10.1177/01455613241285134. Epub ahead of print. PMID: 39315465.
16. Yen DM, Davis GE, Ow RA, O’Malley EM, Del Signore AG. Two-Year Clinical Outcomes After Multipoint Impedance-Controlled Radiofrequency Ablation of the Posterior Nasal Nerve for Treatment of Chronic Rhinitis. Ear Nose Throat J. 2025 Oct 9:1455613251382759. doi: 10.1177/01455613251382759. Epub ahead of print. PMID: 41065547.
17. Reh DD, Lay K, Davis G, Dubin MG, Yen DM, O’Malley EM, Sillers M. Clinical evaluation of a novel multipoint radiofrequency ablation device to treat chronic rhinitis. Laryngoscope Investig Otolaryngol. 2023 Mar 16;8(2):367-372. doi: 10.1002/lio2.1040. PMID: 37090860; PMCID: PMC10116986.

Important Disclaimer Notice (Updated 7/31/14)

Position statements are approved by the American Academy of Otolaryngology–Head and Neck Surgery or Foundation (AAO-HNS/F) Boards of Directors and are typically generated from AAO-HNS/F committees. Once approved by the Academy or Foundation Board of Directors, they become official position statements and are added to the existing position statement library. In no sense do they represent a standard of care. The applicability of position statements, as guidance for a procedure, must be determined by the responsible physician in light of all the circumstances presented by the individual patient. Adherence to these clinical position statements will not ensure successful treatment in every situation. As with all AAO-HNS/F guidance, this position statement should not be deemed inclusive of all proper treatment decisions or methods of care, nor exclusive of other treatment decisions or methods of care reasonably directed to obtaining the same results. Position statements are not intended to and should not be treated as legal, medical, or business advice.