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СпутникиРНSpaceXРоскосмосNASABackground Allergic rhinitis (AR) is a common chronic inflammatory illness of the nasal mucosa that affects quality of life, even if medicine is the first-line treatment. Most moderate to severe persistent AR patients’ symptoms is unsatisfactory despite attempting medication. Modern surgery targets the posterior nasal nerve. This study compared the benefits and safety of surface coablation and posterior nasal nerve resection (PNNR) for persistent allergic rhinitis. Methods In a prospective comparison research, 54 patients (27 per group) aged 18–60 were diagnosed with moderate and severe chronic AR according to ARIA recommendations. One group got endoscopic PNN resection and the other underwent surface coablation. The Total Nasal Symptom Score (TNSS) and Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) assessed baseline and 2-, 6-, and 10-months postoperative outcomes. Results Both therapies significantly reduced TNSS and RQLQ scores from baseline. An improvement of 67–92 percent at 2 months and 46–49 percent at 10 months was seen and sustained. Increasing exercise, sleep, and emotional well-being improved RQLQ scores by 100% at 2 months and > 75% at 10 months. Crustations (11% in PNNR vs. 48% in coablation) and light bleeding (4%) were other minor issues. There were no major issues. Conclusion Posterior nasal nerve excision and surface coablation are safe and efficacious for refractory allergic rhinitis. Surface coablation recovers faster, but posterior nasal nerve resection is more stable and has less problems. These findings suggest both methods can treat persistent allergic rhinitis refractory to medical treatment.
Research Article
[version 1; peer review: awaiting peer review]
1 Department of Surgery - college of medicine, University of Fallujah, Al-Fallujah, Al Anbar Governorate, Iraq
Mustafa A. Husein
Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology
Haider Ibrahim
Roles: Methodology, Project Administration, Resources, Software
Salahaldeen Hosni
Roles: Investigation, Software, Supervision, Validation
OPEN PEER REVIEW
REVIEWER STATUS AWAITING PEER REVIEW
Posterior nasal nerve resection, Allergic rhinitis, Surface coablation, Total Nasal Symptom Score (TNSS), Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ), Nasal neuropathy
Corresponding author: Mustafa A. Husein Competing interests: No competing interests were disclosed.
Grant information: The author(s) declared that no grants were involved in supporting this work.
Copyright: © 2026 A. Husein M et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: A. Husein M, Ibrahim H and Hosni S. A Comparative Study of Posterior Nasal Nerve Resection and Surface Coablation in the Management of Allergic Rhinitis [version 1; peer review: awaiting peer review]. F1000Research 2026, 15:1342 (https://doi.org/10.12688/f1000research.176101.1) First published: 10 Aug 2026, 15:1342 (https://doi.org/10.12688/f1000research.176101.1) Latest published: 10 Aug 2026, 15:1342 (https://doi.org/10.12688/f1000research.176101.1)
Allergic rhinitis (AR) is a common immunoglobulin E (IgE)-mediated inflammatory disease of the nasal mucosa, characterised by two or more of the following symptoms on most days for at least one hour: nasal congestion/obstruction, rhinorrhoea, sneezing, and nasal itching.1 Epidemiological studies estimate a prevalence of up to 20–30% in adults globally, with significant consequent impairments in sleep, daily activities, work productivity and quality of life.2,3
The classification and management of AR were significantly advanced by the ARIA (Allergic Rhinitis and its Impact on Asthma) initiative, which emphasises patient-centred care, severity-based stratification, and the link between upper and lower airway disease (i.e., the “one airway” concept).4 According to ARIA guidelines, first-line therapy for moderate to severe persistent AR includes intranasal corticosteroids, second-generation antihistamines, leukotriene receptor antagonists, and allergen immunotherapy as indicated.5 However, there is a subset of patients who, despite having the most effective medical treatment feasible, continue to experience bothersome symptoms. These symptoms include sneezing, nasal congestion, and rhinorrhea, and these patients may be considering surgical or procedural procedures.6
It is much easier to understand the line of thought behind surgical interventions when one is conversant with the pathophysiology of AR. Immunological reaction an allergic reaction or hyperreactivity reaction (AR) occurs when allergens trigger the mast cells and basophils in the nasal mucosa by means of IgE pathways.7 Some of the mediators released due to this activation are prostaglandins, histamine and leukotrienes. The development of glandular hypersecretion and excessive rhinorrhea is associated with a correlation of the pterygopalatine ganglion and its branches with the parasympathetic innervation of the nasal mucosa.8 Based on this, surgically silencing these circuits has become another form of treatment of individuals who fail to respond to drug. One such intervention is endoscopic Posterior nasal nerve resection (PNNR), whereby the PNN is identified and transected. Clinical studies and systematic reviews support its safety, feasibility and durable efficacy in reducing symptom burden and improving quality of life in patients with refractory AR.9 Alternatively, less invasive procedural approaches such as surface coablation (radio-frequency) of the PNN branches. For example, temperature-controlled radiofrequency ablation of the PNN has demonstrated sustained relief of rhinitis symptoms over a three-year follow-up.10 Despite the potential benefits of these methods, there has been a lack of randomized controlled trials comparing PNN resection with surface coablation for moderate to severe persistent AR, especially when considering the exclusion of concurrent turbinate reduction.11
Given this background, the present study was designed to compare the clinical efficacy, quality-of-life outcomes, and complication profiles of posterior nasal nerve resection versus surface coablation (without turbinate reduction) in patients with moderate-to-severe persistent allergic rhinitis unresponsive to medical therapy.
This was a prospective comparative clinical study conducted to evaluate and compare the outcomes of posterior nasal nerve resection (PNNR) and surface coablation in the management of moderate to severe persistent allergic rhinitis (AR) unresponsive to medical therapy. A total of 54 patients of Fallujah Teaching Hospital in Anbar -Iraq who fulfilled the inclusion criteria and were recruited in the otolaryngology outpatient department from July 2024 to September 2024 were included in the study. All procedures were performed by the same surgical team using standardized protocols. In compliance with the 2013 edition of the Declaration of Helsinki, the study protocol was approved by the Institutional Ethical Committee, and prior to enrollment, signed informed consent was obtained from each participant.
Inclusion criteria.
Patients were eligible for inclusion if they:
• Were aged between 18 and 60 years,
• Were of either sex,
• Were fit for general.
• Had been diagnosed with moderate to severe persistent allergic rhinitis according to the Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines, and
• Had shown poor response to optimal medical therapy for at least 6 months (including intranasal corticosteroids, antihistamines, and leukotriene antagonists).
Exclusion criteria.
The following were excluded:
• Presence of coexisting nasal pathology, such as chronic rhinosinusitis (with or without nasal polyposis), nasal tumors, or granulomatous diseases,
• Immunocompromised status,
• Age below 18 years,
• Previous nasal or sinus surgery, or
• Use of systemic or topical corticosteroids, antihistamines, decongestants, or leukotriene antagonists within one month prior to surgery.
Patient allocation.
A total of 54 patients were divided equally into two treatment groups using a simple randomization method:
• Group A (n = 27): Underwent posterior nasal nerve resection (PNNR).
• Group B (n = 27): Underwent surface coablation of the posterior nasal nerve.
• To make sure that the results showed the real effectiveness of the treatments, neither group had any further nasal operations or turbinate reduction done.
There were no laboratory reagents, chemical agents, and biological materials employed in this research. Standard endoscopic surgical equipment and commercially available radiofrequency surface coablation system commonly used in the practice of otolaryngology were used to perform all interventions. Thus, information about the per-unit quantities of reagents, suppliers and catalogue numbers can not be applied to this study.
Posterior nasal nerve resection (PNNR).
The procedure was performed under endoscopic visualization. After performing a local infiltration with 1% lidocaine and epinephrine (1:100000), an incision was made vertically at the back of the middle meatus above the posterior end of the inferior turbinate in order to expose the sphenopalatine foramen. The branches of the posterior nasal nerve that emerge from below the foramen were painstakingly transected or destroyed using sickle knife or micro-scissors. For the purpose of achieving hemostasis, gelfoam packed on the Flap.
Surface coablation.
In the coablation group, radiofrequency surface coablation was performed using a plasma ablation wand applied to the posterior lateral nasal wall mucosa near the sphenopalatine foramen, targeting the same neural distribution as the PNN. The energy delivery was maintained for few seconds per site until visible blanching of the mucosa occurred. The procedure was performed bilaterally under General anesthesia.
All patients were prescribed saline nasal irrigation twice daily for two weeks and analgesics as required. Topical steroids and antihistamines were not used during six months after surgery to judge the effects of surgery. The review of patients was carried out on 2, 6, and 10 months of post-surgery time.
Signs and symptoms of severity.
To determine the level of symptom improvement, we applied the Total Nasal Symptom Score (TNSS). The scale is a visual analog scale consisting of ten points used to assess nasal blockage, sneezing and rhinorrhea. In this scale 1–3 is mild, 4–7 is moderate and 8–10 is severe. It had assessments conducted on each patient before surgery as well as 2-, 6- and 10-months post-surgery.
Quality of life.
The quality of life was measured on the basis of the Rhino conjunctivitis Quality of Life Questionnaire (RQLQ) which has three major domains; activity limitation, sleep disturbance, and emotional well-being. All items had a rating scale of 7 points (0 = not troubled, 6 = extremely troubled), and depending on the experience of a patient over the last week.
Complications.
Crustation, bleeding, infection or dryness were all intra and postoperative complications and are noted each time the patient was followed up.
Percentage of improvement and grading.
A grading of improvement in TNSS was done as Table 1.
The formula used to calculate the percentage improvement of each of the symptoms was:
Improvement(%)=(Preoperative score−Postoperative score)/Preoperative score×100
The data were organized as well as analyzed with the help of SPSS software (23.0). The quantitative variables were reported in the form of mean (SD) and frequencies (percentage). Paired Student t-test was employed to compare pre- and postoperative scores in each of the groups, whereas the independent t-test was applied to compare the differences between the groups. A p-value lower than 0.05 was deemed to be statistically significant.
In this study, 54 patients who were diagnosed with moderate to severe persistent allergic rhinitis were observed. They were divided into two equal parties:
Group A PNNR (Posterior Nasal Nerve Resection) (n = 27) Coablation of the Surface (Group B) (n = 27). The average age of the participants was 35.0110.5 years old with the range 18–60 years. The difference between the two groups in terms of age, sex distribution, and baseline levels of symptom severity was not significant statistically (p > 0.05).
Total Nasal Symptom Score (TNSS) of nasal obstruction, sneezing and rhinorrhea were measured in preoperative period and 2, 6, and 10 months of postoperative period ( Table 2).
Both the methods demonstrated a significant decrease in TNSS as opposed to baseline. The average total increase in TNSS was 2 months about 69 percent in the PNNR group and 72 percent in the coablation group (p < 0.001). There was a progressive increase in scores at 6 months and 10 months, but at both times an improvement was still significant when compared with the preoperative scores (p < 0.05). The highest reduction was recorded in sneezing and rhinorrhea, whereas nasal obstruction had been partially recurring at 10 months. Even though the initial results were a little bit better in the coablation group, the protracted steadiness was a little better in the resection group. Table 1 demonstrates that both posterior nasal nerve resection (PNNR) and surface coablation brought about significant reductions in Total Nasal Symptom Scores (TNSS) in all symptom domains; nasal obstruction, sneezing, and rhinorrhea relative to preoperative values. Mean obstruction scores decreased from 7 to 4 in the resection group and from 6 to 3 in the coablation group at 2 months postoperatively, indicating the most significant improvement in both groups. Similarly, rhinorrhea went from a 9 to a 2, and sneezing went from an 8 to a 1, respectively. Reduced glandular hypersecretion, vascular permeability, and reflex sneezing responses are the results of cutting off parasympathetic input to the nasal mucosa, which explains these early benefits.
Scores did somewhat increase between 6 and 10 months, but they still stayed in the mild to moderate range, suggesting that the symptomatic benefit persisted. Based on prior research on long-term follow-up of posterior nasal nerve surgeries, this partial symptom return could be caused by peripheral nerve regeneration or incomplete mucosal denervation.12,13
The similar trends observed between both techniques confirm that neural modulation of the posterior nasal nerve—whether by direct transection or thermal ablation effectively suppresses allergic nasal hyperreactivity.14 However, posterior nasal nerve resection provided slightly more stable long-term control of rhinorrhea, consistent with the more complete interruption of parasympathetic fibers achieved by resection compared with the superficial effect of coablation.15 Overall, the results support both approaches as effective, minimally invasive options for patients with refractory allergic rhinitis, in agreement with recent systematic reviews reporting >70% symptom reduction and high patient satisfaction rates.16,17
At two months, > 90% of patients in both groups achieved moderate to marked improvement, reflecting a strong initial therapeutic response. As presented in Table 3, both posterior nasal nerve resection (PNNR) and surface coablation produced substantial symptom improvement among patients with persistent allergic rhinitis. At two months postoperatively, over 90% of patients in each group achieved either moderate (50–74%) or marked (≥ 75%) improvement in Total Nasal Symptom Scores (TNSS), corresponding to statistically significant postoperative gains (p = 0.0021). Only a low percentage of patients (7 percent in the resection group and 11 percent in the coablation group) proved mild improvement and there were no non-responses. This initial advantage is credited to the successful disruption of the parasympathetic nerve supply furnished by the posterior nasal nerve that promotes the hypersecretion of the mucosa, congestion and sneezing reflexes in allergic rhinitis.18 The fact that a somewhat larger percentage of patients receiving PNNR (67% (compared to surface coablation (67% (equal numerically but with marginally increased durability in later follow-up) could be due to the completer and more permanent neural transection that occurs with surgical resection. Coablation, which is less invasive, can still result in remaining viable fibers, or partial reinnervation, which is why it has a propensity to result in mild recurrence of the symptoms in the later follow-up interval.19
Similar improvement rates were found by,20 who noted that cryoablation and neurectomy both improved TNSS by more than 80 percent within a period of six months, and there was no significant difference in the overall efficacy of the two procedures. Similarly, Gerka Stuyt demonstrated that ninety percent of patients achieved prolonged symptom relief one year following PNNR.21 Validated the long-term advantages of temperature-controlled radiofrequency ablation for chronic rhinitis spanning more than thirty-six months.22
When taken as a whole, the findings suggest that posterior nasal nerve modulation, whether it be through resection or surface coablation, provides a considerable and long-lasting improvement in the symptoms of allergic rhinitis. According to the current evidence-based agreement, the fact that a considerable number of patients experienced moderate to marked alleviation by using both approaches demonstrates that they are reliable options for situations that do not respond to medical therapy.
Quality of life improved substantially following both interventions. The Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) scores for the domains of activity, sleep, and emotions are summarized in Table 4.
The RQLQ showed a 100% improvement across all domains at 2 months after the operation (p < 0.001). Both treatments maintained a mean improvement of more than 75% after 10 months, suggesting that patients’ quality of life continued to improve. Specifically, the emotional health of patients and quality of their sleep improved, and they referred to fewer sneezes and congestion in their noses. As indicated in Table 3, the Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) led to significant and sustained patient quality of life following both surface coablation and posterior nasal nerve resection (PNNR). Pretest patients in both groups had reported a high level of functional impairment in all three domains measured (activity limitation, sleep disturbance, and emotional well-being) with mean baseline scores of between 3–6 on a 7-point scale (0 = not troubled, 6 = extremely troubled).
After two months, the mean score of each domain of the two groups was reduced to 0, which implies absolute symptom relief and normal daily functioning (p < 0.001). This theatrical initial advancement is in line with the decrease in nasal congestion, sneezing and nasal secretions documented in the TNSS outcomes and is an indicator of recovery of comfortable nasal breathing and continuous sleep. The improvements in the RQLQ scores (with only minor improvements of 1 point) were mostly sustained throughout the six and ten months, which suggests a long-term benefit.
The little increase at 10 months could be due to partial reinnervation of posterior nasal nerve fibers or prolonged contact with allergens as has been observed in other long-term follow-ups of posterior nasal nerve treatments.23 Compared to coablation, patients undergoing PNNR demonstrated a slightly more stable score over time, particularly in the sleeping and emotion areas, which hints at the longer-term effect of denervation. These results are in line with earlier studies that have demonstrated that surgery on the posterior nasal nerve or ablation gives great advantage in patient-reported quality of life (RQLQ or mini-RQLQ) that extends well past 12 months.24 Found that both cryoablation and posterior nasal neurectomy improved quality of life in a randomized clinical study, with a mean RQLQ improvement of over 75% at six months.25 A similar study by Maddineni et al. showed that the posterior nasal nerve may be targeted with temperature-controlled radiofrequency ablation, leading to long-lasting improvements in RQLQ scores that lasted for up to three years.26 The overall data from the current study, therefore, reinforce that both PNNR and surface coablation not only reduce objective nasal symptoms but also translate into a clinically meaningful and lasting improvement in patients’ daily activity, sleep, and psychological well-being, in line with contemporary literature.9,13
Minor postoperative complications were recorded in both groups ( Table 5).
Coablation increased the incidence of crust development, after two to three weeks of saline treatment, disappeared on its own. In the PNNR group, there was one case of mild bleeding that was carefully managed. There were no serious side effects observed in either group, including infection, septal perforation, atrophic rhinitis, or anosmia. Table 4 shows that both surface coablation and posterior nasal nerve resection (PNNR) had low rates of postoperative complications and were well-tolerated treatments. Three patients (11% in the resection group and thirteen (48% in the coablation group)) experienced nasal crustation, the most common mild consequence (p = 0.003). The conventional explanation for crust development after surface coablation is that the mucociliary recovery is delayed and the epithelial cells are temporarily killed off due to thermal injury and superficial mucosal desiccation caused by radiofrequency energy application.27 The reduced crustation rate is a result of the careful endoscopic dissection that occurs during PNNR at the sphenopalatine foramen with little surface trauma. These results are in agreement with those of Chang et al., who found that temporary mucosal crusting was more common following radiofrequency posterior nasal nerve ablation than surgical resection.28
One patient (4% of the total) in the PNNR group experienced minor bleeding, which stopped on its own after conservative nasal packing. Radiofrequency energy has a coagulative action that plugs small submucosal arteries intraoperatively, which is probably why the coablation group did not have any bleeding.29 Importantly, neither group experienced significant problems including infection, septal perforation, atrophic rhinitis, or olfactory impairment, suggesting that the treatments are safe and minimally invasive.
Similarly, prior multicenter investigations have shown that procedures involving the posterior nasal nerve had very low risk profiles. Mild transitory crusting was found in 9% of cases with no serious adverse effects in a sample of 291 patients having temperature-controlled radiofrequency ablation.30 Similarly, Adly Abdelmoety and colleagues found that less than 5% of patients who had cryoablation or neurectomy experienced crusting and self-limiting hemorrhage.31 Coablation reduces intraoperative bleeding but increases the incidence of transient mucosal crustation owing to surface tissue effects; both PNNR and surface coablation are clinically safe procedures, according to the present results. Both surface coablation and PNNR continued to provide substantial functional and clinical advantages at the 10-month follow-up. While the average increase in RQLQ was more than 75%, the average improvement in sustained TNSS was about 47% to 49%. Coablation patients reported somewhat faster postoperative comfort and recovery than PNNR patients, who had less crustations and longer-lasting management of rhinorrhea. Both procedures were evaluated for their safety, effectiveness, and tolerability. No major adverse events were reported.
For patients with moderate to severe allergic rhinitis who were not responding to pharmacological treatment, surface coablation and posterior nasal nerve excision both markedly improved symptoms and quality of life. Resection offered more robust long-term control, particularly for rhinorrhea, but coablation offered somewhat quicker early postoperative relief. Crustation was more frequent during coablation, and one resection case experienced mild hemorrhage, but other complications were minor and self-limiting. Both procedures are generally safe, efficient, and minimally invasive; posterior nasal nerve resection guarantees longer-lasting benefits, while surface coablation is most suited for individuals who want a speedier recovery.
This study was conducted in accordance with the ethical principles of the Declaration of Helsinki (2013). Ethical approval was obtained from the Institutional Ethics Committee of Fallujah Teaching Hospital, College of Medicine, University of Fallujah, Anbar, Iraq.
At the time of approval, the committee did not assign a formal reference or approval number for single-center, investigator-initiated clinical studies; therefore, no ethics approval number is available for this study.
The study was reviewed and approved by the host institution’s ethics committee, and no additional external review board approval was required. Written informed consent was obtained from all participants prior to enrollment. Participants were fully informed about the study objectives, procedures, potential risks, and benefits. Confidentiality and anonymity of all patient data were strictly maintained throughout the study.
The anonymized individual-level dataset underlying the results reported in this article is publicly available in the Zenodo repository at: https://doi.org/10.5281/zenodo.18507621.32
Mustafa A. Husein, Haider Salih Ibrahim, & Salahaldeen Badeea Hosni. (2026). Dataset and extended data for: A Comparative Study of Posterior Nasal Nerve Resection and Surface Coablation in the Management of Allergic Rhinitis [Data set]. Zenodo. https://doi.org/10.5281/zenodo.19736908.33
The dataset includes demographic data, group allocation, TNSS values at all time points, RQLQ domain scores, values underlying tables, and documented postoperative complications.
All data are fully anonymized and are released under a Creative Commons Attribution 4.0 International (CC-BY 4.0) license. The dataset is freely accessible without embargo or login restriction.
Extended data related to this research are publicly available in the Zenodo repository at:
https://doi.org/10.5281/zenodo.18507621.32
The extended data include:
• The Total Nasal Symptom Score (TNSS) assessment form;
• Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ);
• Criteria used to grade TNSS percentage improvement;
• A sample participant information sheet;
• A blank informed consent form used in the study.
All materials are released under a Creative Commons Attribution 4.0 International (CC-BY 4.0) license and are freely accessible without embargo or login restriction.
The authors would also like to acknowledge the staff of the Otolaryngology Department at Fallujah Teaching Hospital, Anbar, Iraq that helped them to recruit and follow-up on patients. The surgical and nursing teams are given a special consideration on their assistance in conducting the procedures and on providing quality postoperative care. The authors further make the acknowledgment of the support given to them by the Institutional Ethics Committee in the study. Above all, the authors must recognize that the patients who took part in this study contributed to this study by cooperating and trusting.
The author(s) declared that no grants were involved in supporting this work.
© 2026 A. Husein M et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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