Vidian Neurectomy

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Severe Intractable Watery Rhinorrhea
unresponsive to intranasal Steroids/ Atrovent
Highly Successful
Major risks:
­  Bleeding
­  Drying of Eye
­  Failure to control symptoms
Sup.
Salivary
nucleus
VII
Sup
Petrosal
nerve
PARASY
MP
IX
Greater
deep
Petrosal
Nerve
SYMP
Pericarotid
SYMP
Vidian Nerve
V2
Sensor
y
fibers
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Sphenopalatin
e ganglion
Lacrim
al
nerve
S
P
F
Posterior
Nasal
Nerve
Palata
l
nerve
Not first line management- last resort
Intractable Vasomotor rhinitis (NAR)
unresponsive to treatment
Allergic rhinitis unresponsive to treatment
Treatment includes antihistamines, topical/
systemic steroids/topical anti-cholinergics/
tissue volume reduction of inferior turbinates/
SIT/SLIT. Allergen avoidance
1 11/13/14 ¨ 
Transient cheek & dental numbness – damage
to maxillary nerve (foramen rotundum)
Nasal crusting, dryness
Initiation of bronchial asthma
Ocular complications
Bleeding
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Kamel & Zaher. 1991 first used endoscopic sub periosteal
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El Shazly, El-Guindy. 1994 (endoscopic transeptal
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Robinson & Wormald. 2006 (endoscopic SPF) SPA
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Caldwell Luc approach (transantral)
Transpalatal
Transnasal – septum
Transnasal microscopic
Endoscopic
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Golding-Wood 1972- n=185
5-15 year follow up 94% relief rhinorrhea
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approach behind SPF (n=15 cadavers, n=16 patients)
approach on face of sphenoid) n=11
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Krant 1979- 71% long term recurrence
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Dry Eye reported postoperatively
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Yin recurrence of 66% at 1 year, 85% after 5
years (1990)
cauterised, SPF identified first, then ant face sphenoid
was opened. Then SPF was enlarged posteriorly up to
ant face sphenoid exposing periost of PPF. Incised and
transected Vidian nerve before entry into PPF
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Lee endoscopic. 2009 transphenoid / Intra sphenoidal
approach for embedded Vidian canal with CT imaging
n=100
Lee* recommended scanning all patients
Classified 3 types of Vidian nerve position
Recommended type 1 & 2 INTRA sphenoid
approach
Type 3 TRANSsphenoid approach
Lee J-C & Lin Y-S. Endoscopic Vidian Neurectomy: update on techniques &
evidence.
Curr Opin Otolaryngol Head Neck Surg 2012, 20:66-72
2 11/13/14 Authors
Significa No significant
nt
changes
improve
ment
Number Follow up
patients period
Side effects
Robinson
&
Wormald
2006
Rhinorrh Sneezing worse in
ea
3/14 patients
Nasal
Obstructi
on
14
35% mild
occasional eye
dryness
1 permanent
28% nasal
crusting
Jang et al
2010
Rhinorrh
ea
Nasal
Obstructi
on
(VAS)
Lee et al.
2011
91%
satisfied
Tan et al
2012
64%
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2 years
7/14 deemed
operation to
be highly
successful
No change in
6
sneezing/itchiness
1/6 patient worse
after operation
7 years
No
additional
treatment
antihistamine
/steroids
Mild dry eyes for
1 month
1> 2 months
Shirmers pre
post op day 1,
30,60
Crusting
84
1.5 years
23% dry eyes
post op
93
6 years
30% dry eyes
30d
8% permanent
236 patients self selected one of three
treatments
Bilateral VN (n=93)/ Septoplasty + inf
turbinectomy (n= 51)/nasal steroids for 3
months (n=92)
Follow up at 6months, 1 year & 3 & 6 years
Rhinoconjunctivitis Qol questionnaire
After 6 years 64.7% vs. 6.5% vs. 1.5% much
improved
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*Long term effectiveness and safety of endoscopic VN
CEO vol. 3,No 4 Dec 2010
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Troublesome bleeding/fat in PPF
Technically challenging
Narrow operative field
Incorrect identification nerve (pharyngeal
Nerve)
Incomplete resection of nerve
Regeneration nerve ? synkinesis
Safety and complications
30.6% dry eyes resolved after one month with
sodium hyaluronate eye drops
8.2% no tears with sadness or pain
15% mild nasal dryness
9% numbness upper lip –resolved after 12
months
Tan G et al. Arch Otolaryngol Head Neck Surg ,2012,. 138 492-7
Tan G et al. Arch Otolaryngol Head Neck Surg ,2012,. 138 492-7
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Loss of post ganglionic secretomotor fibers to
lacrimal gland
Incidence in literature of 12-30%
Jang TY * Shirmers test pre op, day 1 , 1& 2
months post op. All patients dry eye but
improved by 2 months
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Non selective autonomic denervation of the
Pterygopalantine ganglion
Similar to a Vagotomy. Is there another
approach e.g. Highly selective Vagotomy and
will we doing this in the future
VN is an evolving operative concept
3 11/13/14 ¨ 
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Ikeda*- performed posterior nasal nerve
(PNN) Neurectomy to replace VN as it
emerged from SPF (2006) together with Inf
turbinate submucous resection.
Describes PNN as PARAsymp and SYMP fibers
always exiting SPF
Describes favorable results but 42%
submaximal improvement
.
Ikeda K, Osh et al.Acta Otolaryngol. 2006 Jul;126(7):739-45
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Challenge our anatomical teaching of post
ganglionic fibers
showed multiple individual postganglionic rami
to nasal mucosa from PPG (posterior superior to
horizontal attachment of IT) 14/16 cadaver sides
2 principal groups fibers and don’t traditionally
follow trigeminal nerves
Rami sphenoethmoidalis and rami
orbitonasalis(ant/post ethmoidal foramen)
3rd group-rami lacrimalis to orbital apex
Showed that nasal mucosa is innervated by
array of multiple small neurovascular fascicles
through multiple fissures and foramina and not
just SPF
Anastamoses throughout palatine bone and
loops with SPF and other nerves
Possibility of selective postganglionic
pterygopalantine parasymapthectomy (SP3)
and avoid rami lacrimales and spare rami
orbitofrontalis.
Also preserve sympathetic function and
increase tone and decrease congestion/nasal
obstruction
Bleier S & Schlosser R. Int Forum Allergy & Rhinology Vol1, no 2
2011
*International Forum of Allergy & Rhinology, Vol. 1, No. 2, March/
April 2011
Sydney Rhinology Technique
Success Rate for resolution of symptoms high
Complication rate following VN in both Tumour
and Rhinitis patients appears extremely low
SO– Currently performing
1.Meta-analysis and systematic review of
literature to assess success
2.Prospective Study of Complications using
PROMs , Schirmers Test and Dry Eye QOL
questionnaires
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