The Laryngoscope

Lippincott Williams & Wilkins, Inc., Philadelphia

2003 The American Laryngological,
Rhinological and Otological Society, Inc.

Radiofrequency for the Treatment of

Allergic Rhinitis Refractory to Medical
Therapy
Hsin-Ching Lin, MD; Pei-Wen Lin, MD; Chih-Ying Su, MD; Hsueh-Wen Chang, PhD

Objectives/Hypothesis: The ideal treatment for allergic rhinitis refractory to medical therapy is still
lacking. The aim of the study is to evaluate the efficacy of turbinate surgery with radiofrequency for the
treatment of allergic rhinitis that is unresponsive to
medical therapy. Study Design: A prospective, nonrandomized clinical study. Methods: From February
2000 to April 2002, 108 consecutive patients (45 men
and 63 women [mean age, 29.5 y]) with allergic rhinitis refractory to medical therapy who underwent radiofrequency turbinate surgery were enrolled in the
study. Postoperative follow-up ranged from 12 to 26
months. A standard 0-to-10 visual analogue scale with
an anchor was used to assess the pain and the allergic
symptoms, including nasal obstruction, rhinorrhea,
sneezing, itchy nose, and itchy eyes, preoperatively
and postoperatively at the end of weeks 1 and 2 and
months 1, 3, 6, and 12 after surgery. Statistical analysis was determined by repeated measures of ANOVA.
Results: None of the 108 patients had obvious discomfort other than mild numbness over the premaxillary
area (24 of 108 [22.2%]) during operation. Also, no
adverse reactions including bleeding, infection, adhesion, or a worsening of allergic symptoms were encountered. One hundred one patients were included
in the final statistical analysis. Only nine patients
reported no improvement at all after treatment. The
response rate of radiofrequency turbinate surgery for
allergic rhinitis refractory to medical therapy was
91.1% (92 of 101). At 1 year after the treatment, the
degree of nasal obstruction had changed on the visual
analogue scale (mean SD) from 6.84 2.09 to 2.47
1.60, an improvement of 63.9%. The degree of rhinorrhea had changed from 5.74 2.75 to 2.57 2.31, an
Presented in part at the 105th Annual Meeting of the American
Academy of OtolaryngologyHead and Surgery, Denver, CO, September
9 12, 2001.
From the Departments of Otolaryngology (H-C.L., C-Y.S.) and Ophthalmology (P-W.L.), Chang Gung University, Chang Gung Memorial Hospital,
Kaohsiung Medical Center, and the Department of Biological Sciences
(H-W.C.), National Sun Yat-Sen University, Kaohsiung, Taiwan.
Editors Note: This Manuscript was accepted for publication December 5, 2002.
Send Correspondence to Chih-Ying Su, MD, Department of Otolaryngology, Chang Gung Memorial Hospital, Kaohsiung Medical Center, No.
123, Ta-Pei Road, Niao-Sung Hsiang, Kaohsiung Hsien, 833, Taiwan.
E-mail: usgniy@adm.cgmh.org.tw

Laryngoscope 113: April 2003

improvement of 55.2%. The degree of sneezing had

changed from 5.30 2.80 to 2.59 2.13, an improvement of 51.1%. The degree of itchy nose had changed
from 3.74 3.16 to 1.82 2.27, an improvement of
51.3%. The degree of itchy eyes had changed from 3.17
3.09 to 1.68 2.38, an improvement of 47.0%. The
visual analogue scale scores for nasal obstruction,
rhinorrhea, sneezing, itchy nose, and itchy eyes decreased significantly with time, from preoperative
scores to scores at 1 year after surgery. Other additional effects and improvements, including headache,
lumpy throat, night cough, and tinnitus, were also
reported by the patients. Most of the patients stated
that they would consider repeating this procedure if
necessary and would recommend the new method to
their friends with the same problems. Conclusions:
The study demonstrates that radiofrequency appears
to be an effective and safe tool for treating allergic
rhinitis with poor response to medical therapy. In the
future, radiofrequency has the potential to be one of
the most popular surgical modalities for the treatment of allergic rhinitis refractory to medical therapy. Key Words: Radiofrequency, allergic rhinitis,
nasal turbinate.
Laryngoscope, 113:673 678, 2003

INTRODUCTION
Allergic rhinitis, one of most common otolaryngological disorders, is a bothersome but not a life-threatening
disease. It not only interferes with the quality of a patients daily life but also induces intangible loss on his or
her physical, emotional, and even socioeconomic functioning. Most of the patients have been treated with conventional pharmacotherapy such as antihistamines, decongestants, anticholinergic agents, mast cell stabilizers,
intranasal steroid sprays, and allergen desensitization.1
However, some intractably allergic patients remain, as
well as some inconvenience for those who have used these
medicines over a long term. When conservative therapy
has failed to relieve the symptoms of allergic rhinitis,
many turbinate surgical procedures such as cryosurgery,
electrocautery, laser turbinectomy, partial or total turbinectomy, and vidian neurectomy have been employed with
various effects. Because of direct mucosal manipulation
during those surgical procedures, adverse events includLin et al.: Radiofrequency for Allergic Rhinitis

673

ing bleeding, pain, crusting, foul odor, nasal dryness, synechia or bone necrosis, and the need for nasal packing may
occur.2 8
In recent years, radiofrequency (RF) surgery has
been widely applied to various otolaryngological disorders
including simple snoring, sleep-related disorders, nasal
obstruction due to turbinate hypertrophy, and obstructive
tonsillar hypertrophy.9 19 The safety and efficacy of RF
turbinate surgery for hypertrophied turbinate has been
well demonstrated with respect not only to subjective improvement of the symptoms, but also to objective changes
in nasal function.20 Compared with the traditional surgical procedures, the main advantages of RF surgery are the
sparing of the overlying mucosa and the decrease in operative morbidity and postoperative complications. To the
best of our knowledge, the feasibility and efficacy of RF
turbinate surgery in patients with nasal allergy has not
been fully addressed in the literature.

PATIENTS AND METHODS

Populations
From February 2000 to April 2002, 108 consecutive patients
(45 men and 63 women) with allergic rhinitis refractory to medical treatment were prospectively enrolled in the study. All of the
patients underwent RF surgery of the inferior turbinates and
were observed postoperatively for more than 1 year. The age of
the patients ranged from 11 to 70 years (mean age, 29.5 y).

tion of each inferior turbinate. Radiofrequency energy was delivered at a frequency of 465 Hz by an RF generator (model S2
radiofrequency control unit, Somnus Medical Technologies, Inc.,
Sunnyvale, CA) and an SP 1100 turbinate handpiece (40-mmlong needle electrode consisting of a 10-mm active portion, 30-mm
insulated part, and two thermocouples). The active 10-mm portion of the electrode and at least 2 mm of the insulation were
placed submucosally within the anterior portion of each inferior
turbinate (two punctures per turbinate, one facing to the common
meatus and parallel to the septum and the other facing the
inferior meatus and parallel to the nasal floor) under direct vision
using a fiberoptic headlight and nasal speculum (Figs. 1 and 2).
The energy (mean SD) delivered for puncture site A was 365.3
76.8 J and for puncture site B was 425.0 71.4 J; total dose
was 1580.1 277.1 J with an approximate duration of 1 to 2
minutes at a plateau temperature of 75C and low-level energy of
10 W. All patients underwent a single RF turbinate surgery with
four punctures. After completion of the procedure, cotton pledgets
soaked with a mixture of 4% lidocaine and 0.1% epinephrine (1:1)
were temporarily placed over the puncture sites for 5 to 10 minutes. Each patient was discharged without any limitation of normal daily activities. No nasal packing was administered, nor were
antibiotics, antihistamines, analgesics, or nasal spray prescribed.
Local findings of the nasal cavities and assessment of treatment
efficacy were recorded in detail at each follow-up session.

Evaluation
All of our patients with allergic rhinitis had typical clinical
symptoms and signs, as well as a high titer of specific immunoglobulin E (IgE) antibodies for house dust and/or other antigens.
They had been previously treated with conventional medical
management without satisfactory improvement for at least 3
months. Patients with systemic disease, previous turbinate surgery, severe nasal septal deviation, nasal polyposis or sinusitis,
upper respiratory tract infection within a week preoperatively, a
history of radiotherapy, or oral steroid use were excluded. The
patients were also assessed by an ophthalmologist to exclude any
ophthalmological disorder that may induce the symptom of eye
pruritus such as trichiasis, entropion, blepharitis, blepharoconjunctivitis, keratoconjunctivitis, or dry eye syndrome, as well as
the use of topical eyedrops of antihistamine, corticosteroid, or
mast cell stabilizer.
Objective evaluations of the intranasal findings were investigated by anterior rhinoscope or endoscopic examinations. A
standard visual analogue scale (VAS) with an anchor (ranging
from 0 to 10, with 0 representing no symptoms and 10 representing the most severe symptoms) was used to assess the allergic
patients subjective symptoms including nasal obstruction, rhinorrhea, sneezing, itchy nose, and itchy eyes preoperatively and
at the end of weeks 1 and 2 and months 1, 3, and 6, and 12 after
surgery.
Postoperative pain was also graded on a VAS ranging from
0 to 10. The patients were asked not to use oral steroids, antihistamines, decongestants, or topical nasal sprays containing corticosteroids or mast cell stabilizers during the follow-up period.

Surgical Procedure
All surgical procedures were performed by the first author
(H-C.L.) in an outpatient facility. The operation was performed
with the patient under local anesthesia consisting of sprays with
10% lidocaine (two puffs per nostril) and infiltration with 2%
lidocaine (total amount, 2 4 mL) injected into the anterior por-

Laryngoscope 113: April 2003

674

Fig. 1. Coronal view of radiofrequency energy being delivered. Two

punctures per turbinate are performed: point A faces the common
meatus and parallels the septum and point B faces the inferior
meatus and parallels the nasal floor.

Lin et al.: Radiofrequency for Allergic Rhinitis

Fig. 2. Sagittal view of radiofrequency energy being delivered. The active 10-mm portion of the electrode and at least 2 mm of the insulation
are inserted submucosally within the anterior portion of the inferior turbinate and an ovoid lesion is created.

Statistical Analysis
Results were expressed as mean SD. Comparisons of
scores for the common symptoms of allergic rhinitis (including
nasal obstruction, rhinorrhea, sneezing, itchy nose, and itchy
eyes) generated with VAS preoperatively and postoperatively
were made using repeated measures of ANOVA. When significant
differences were noted, individual means were compared using
the Scheffe test. Differences were considered to be statistically
significant when the P value was less than .05.

RESULTS
None of the 108 patients reported obvious discomfort
other than a mild numbness over the premaxillary area
(24 of 108 [22.2%]) during operation, which immediately
subsided when the delivery of RF energy was finished.
Also, no other adverse reactions including crusting, bleeding, infection, adhesion, dryness, or synechia were encountered (Fig. 3). There were 13 patients (12.0%) who reported having mild postoperative pain, which was scored
at 2 or less. A transient worsening of symptoms in nasal
obstruction and/or nasal secretion was reported by 67
patients (62.0%), all cases occurring only within the first 3
postoperative days. No analgesics were prescribed in the
entire study, and no analgesics were requested by the
patients.
Of the seven cases excluded from the study, one patient developed hepatoma 3 months after surgery, two
patients received a local application of Chinese herbal
drugs during the early postoperative period, and four patients were lost in follow-up. One hundred one patients
were enrolled in the final related long-term statistical
analysis. In the series of 101 patients with allergic rhinitis, only 9 patients reported no improvement of any allergic rhinitis symptoms after treatment. The response rate
of RF turbinate surgery for these patients with allergic
rhinitis refractory to medicine was 91.1% (92 of 101). The
RF treatment outcome assessments for the common symptoms of allergic rhinitis in the 92 patients at each
Laryngoscope 113: April 2003

follow-up time are summarized in Table I and shown in

Figure 4. The follow-up period ranged from 12 to 26
months, with a mean follow-up period of 19.4 months.

Nasal Obstruction
The VAS scores (mean SD) for nasal obstruction as
graded by the patients changed from a preoperative score
of 6.84 2.09 to postoperative scores of 4.24 2.45 at 1
week, 3.32 2.06 at 2 weeks, 2.64 1.79 at 1 month, 2.46
1.61 at 3 months, 2.45 1.62 at 6 months, and 2.47
1.60 at 12 months. The average degrees of improvement of
nasal obstruction at the end of weeks 1 and 2 and months
1, 3, 6, and 12 were 38.0,% 51.5,% 61.4,% 64.0,% 64.2,%
and 63.9%, respectively.

Rhinorrhea
The VAS scores (mean SD) for rhinorrhea as
graded by the patients changed from a preoperative score
of 5.74 2.75 to postoperative scores of 4.03 2.69 at 1
week, 3.46 2.38 at 2 weeks, 2.90 2.19 at 1 month, 2.66
2.25 at 3 months, 2.60 2.34 at 6 months, and 2.57
2.31 at 12 months. The average degrees of improvement of
rhinorrhea at the end of weeks 1 and 2 and months 1, 3, 6,
and 12 were 29.8%, 39.7%, 49.5%, 53.7%, 54.7%, and
55.2%, respectively.

Sneezing
The VAS scores (mean SD) for sneezing as grade by
the patients changed from a preoperative score of 5.30
2.80 to postoperative scores of 3.38 2.41 at 1 week, 3.13
2.29 at 2 weeks, 2.85 2.15 at 1 month, 2.55 2.13 at
3 months, 2.52 2.17 at 6 months, and 2.59 2.13 at 12
months. The average degrees of improvement of sneezing
at the end of weeks 1 and 2 and months 1, 3, 6, and 12
were 36.2%, 40.9%, 46.2%, 51.9%, 52.5%, and 51.1%,
respectively.
Lin et al.: Radiofrequency for Allergic Rhinitis

675

at 3 months, 1.67 2.00 at 6 months, and 1.82 2.27 at

12 months. The average degrees of improvement of itchy
nose at the end of weeks 1 and 2 and months 1, 3, 6, and
12 were 51.3%, 53.7%, 57.5%, 57.0%, 55.3%, and 51.3%,
respectively.

Itchy Eyes
The VAS scores (mean SD) for itchy eyes as graded
by the patients changed from a preoperative score of 3.17
3.09 to postoperative scores of 1.78 2.60 at 1 week,
1.60 2.35 at 2 weeks, 1.29 2.00 at 1 month, to 1.47
2.18 at 3 months, 1.32 2.00 at 6 months, and 1.68 2.38
at 12 months. The average degree of improvement of itchy
eyes at the end of weeks 1 and 2 and months 1, 3, 6, and
12 were 43.8%, 49.5%, 59.3%, 53.6%, 58.4%, and 47.0%,
respectively.
In the present series, the VAS scores for nasal obstruction, rhinorrhea, sneezing, and nasal and ophthalmological pruritus decreased significantly with time, from
before surgery to 1 year after surgery (Scheffe test, P
.0001).

Additional Effects and Follow-Up

In two male patients who had both allergic rhinitis
and habitual snoring, RF turbinoplasty in combination
with RF palatoplasty was carried out by using an SP 1010
RF palate handpiece. They had improvement not only in
the symptoms of allergic rhinitis but also in the severity of
snoring.
Additional postoperative improvements of the other
symptoms including headache, lumpy throat, night cough,
and tinnitus were also reported by patients. Twenty-one
patients have been followed up for more than 2 years. All
patients reported that they would consider repeating this
procedure if necessary, and would recommend the new
method to their friends with the same disorder.

DISCUSSION

Fig. 3. Endoscopic views of inferior turbinate (no topical vasoconstriction agents were applied before obtaining the images). (A) Preoperative view. (B) Postoperative view. No superficial mucosal damage was noted. (C) One month postoperatively. The patency of the
anterior nasal cavity obviously increases. S, septum; T, inferior
turbinate.

Itchy Nose
The VAS scores (mean SD) for itchy nose as graded
by the patients changed from a preoperative score of 3.74
3.16 to postoperative scores of 1.82 2.37 at 1 week,
1.73 2.29 at 2 weeks, 1.59 2.05 at 1 month, 1.61 2.04
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676

Although RF energy has been widely used in various

medical fields for years, it was first used in the otolaryngological field by Powell et al. in 1997.21 To date, RF tissue
volume reduction has been extensively applied to the targets of upper airway disorders, including the nasal turbinates, soft palate, base of the tongue, and tonsils. With
respect to RF turbinate surgery, most of the previous
studies focused their attention only on the problems of
nasal patency resulting from inferior turbinate hypertrophy.14 18,20 In the current study, we investigated the efficacy of RF turbinate surgery emphasizing the common
symptoms of allergic rhinitis.
The investigation of the histological changes caused
by RF surgery revealed that a well-circumscribed submucosal scar lesion with normal healing progression in the
target site is stably formed at 3 weeks postoperatively.21
Our results are compatible with the histological study.
The effect of RF turbinoplasty for allergic rhinitis may
vary at the end of 1 or 2 weeks postoperatively, but it
achieved a relatively obvious and stable improved status
in relation to the symptoms of allergic rhinitis 1 month
later. One month after treatment, 96.7% of these patients
obtained significant improvement of nasal obstruction,
Lin et al.: Radiofrequency for Allergic Rhinitis

TABLE I.
The VAS Records (mean SD) of the Symptoms of Allergic Rhinitis at Each Follow-up Time.

Nasal obstruction
Rhinorrhea
Sneezing
Itchy nose
Itchy eyes

Pretreatment

1W

2W

1M

3M

6M

1Y

P*

6.84 2.09
5.74 2.75
5.30 2.80
3.74 3.16
3.17 3.09

4.24 2.45
4.03 2.69
3.38 2.41
1.82 2.37
1.78 2.60

3.32 2.06
3.46 2.38
3.13 2.29
1.73 2.29
1.60 2.35

2.64 1.79
2.90 2.19
2.85 2.15
1.59 2.05
1.29 2.00

2.46 1.61
2.66 2.25
2.55 2.13
1.61 2.04
1.47 2.18

2.45 1.62
2.60 2.34
2.52 2.17
1.67 2.00
1.32 2.00

2.47 1.60
2.57 2.31
2.59 2.13
1.82 2.27
1.68 2.38

.0001
.0001
.0001
.0001
.0001

*Overall significance by repeated measures of ANOVA.

VAS standard 0 10 visual analog scale.

Fig. 4. The average degree of improvement of nasal allergic symptoms at each follow-up time postoperatively (derived from the
change in visual analogue scale (VAS) score (range, 0 10) after
radiofrequency turbinate surgery).

with the VAS score (mean SD) changing from 6.84

2.09 to 2.64 1.79, an improvement of 61.4%. The VAS
score for rhinorrhea changed from 5.74 2.75 to 2.90
2.19, an improvement of 49.5%. The VAS score for sneezing changed from 5.30 2.80 to 2.85 2.15, an improvement of 46.2%. The VAS score for itchy nose changed from
3.74 3.16 to 1.59 2.05, an improvement of 57.5%. The
VAS score for itchy eyes changed from 3.17 3.09 to 1.29
2.00, an improvement of 59.3%. During the follow-up
period (Fig. 4) the symptoms of nasal obstruction, rhinorrhea, and sneezing improved stably with time, with the
average degrees of reduction of severity of nasal obstruction, rhinorrhea, and sneezing at 1 year postoperatively
being 63.9%, 55.2%, and 51.1%, respectively. Although the
RF effects on the symptoms of itchy nose and eyes seemed
to be less obvious and had a mildly decreasing tendency,
the differences were still considered to be statistically
significant when compared with the preoperative status.
Regarding the sustainable effect of RF surgery on
allergic rhinitis, 21 patients have been followed up for
more than 2 years. In most of them, the treatment outcomes showed no obvious subsidence with the additional
follow-up time. Among these patients, the VAS scores for
nasal obstruction, rhinorrhea, sneezing, itchy nose, and
itchy eyes changed from 6.43 2.27, 6.29 2.41, 6.05
2.56, 2.81 3.25, and 2.00 2.66 preoperatively to 1.90
1.84, 2.62 2.24, 3.00 2.32, 1.43 2.36, and 0.81 1.83
at 2 years after RF surgery. Two years after the RF treatment, the average degrees of reduction of severity of nasal
obstruction, rhinorrhea, sneezing, itchy nose, and itchy
eyes were 70.5%, 58.3%, 50.4%, 49.1%, and 59.5%,
respectively.
Laryngoscope 113: April 2003

Two of our patients had both allergic rhinitis and

habitual snoring preoperatively. We used the RF SP 1010
palate handpiece to perform the turbinate surgery first,
then bent the electrode to carry out RF palatoplasty. The
result revealed an improvement in allergic symptoms,
snoring, and quality of sleep. Radiofrequency turbinate
surgery combined with RF palatoplasty could be an effective method for patients with nasal allergy with mild
sleep-disordered breathing. This combined surgery would
be more cost-effective than performing the two procedures
separately. We also found that RF surgery had additional
postoperative effects on the concomitant symptoms in the
patients with allergic rhinitis as well. Some allergic patients, who also had headaches, lumpy throat, night
cough, posterior nasal dripping, and tinnitus preoperatively, had improvement not only in the allergic symptoms
but also in these additional discomforts after RF surgery.
Haight and Cole22 reported that the resistance of the
nasal airway significantly increased over the anterior
ends of the inferior turbinates and nasal valve region. The
mechanism of RF turbinate surgery in relieving the symptom of nasal obstruction was mainly based on the tissue
volume reduction of the anterior portion of the inferior
turbinate by RF energy. Because the superficial submucosal layer of the inferior turbinate was thought to be the
site where the allergic reaction occurred,7 we assumed
that the superficial surface area for allergen contact would
decrease after RF turbinate surgery. The consequence of
RF energy in the submucosa of the inferior turbinate, such
as circumferential scar formation, obliteration of the submucosal small vessels, and destruction of the submucosal
glands, is thought to be a major factor for the RF effects on
allergic rhinitis. In addition, there might also be a reaction
to inhibit the local immune response and the passage of
histochemical mediators. Further investigations are
needed.
We performed the RF turbinoplasty (one procedure
with four punctures) for each of our patients. The insertion sites limited to the anterior portion of the inferior
turbinate were sufficient to obtain a satisfactory result.
None of our positively responding patients underwent a
revision RF surgery in the follow-up period. The current
study revealed that RF turbinoplasty is a minimally invasive and well-tolerated surgery, and the middle-term results of this procedure for allergic rhinitis were
encouraging.
Lin et al.: Radiofrequency for Allergic Rhinitis

677

CONCLUSION
The study suggests that RF is an effective and safe
tool for treating allergic rhinitis refractory to medical
therapy. Radiofrequency turbinate surgery can significantly improve the symptoms of allergic rhinitis. If the
further long-term studies confirm these results, radiofrequency may have the potential to be a surgical modality of
choice for allergic rhinitis refractory to medical therapy.

Acknowledgments
The authors thank Mei-Ling Kao for her assistance in
the preparation of the manuscript and Jui-Hsin Chen for
his assistance in drawing the illustrations.

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