With the continuous evolution of medical practices, the National Institute for Health and Care Excellence (NICE) has recently updated its recommendations regarding the utilization of cryotherapy (cold therapy) for managing chronic rhinitis in affected patients. This revision reflects a proactive approach towards optimizing therapeutic strategies and ensuring the highest standards of care for individuals grappling with this persistent nasal condition. In this context, it becomes imperative to delve deeper into the specifics of these updated guidelines, exploring their implications for clinical practice and patient outcomes.

 

(A) Recommendations

In accordance with the NICE interventional procedures guidance, cryotherapy for chronic rhinitis is advocated only for research purposes. Additional investigation is warranted to determine the duration of effects (including whether there is a requisition of repeat procedures), patient selection, and long-term outcomes. Current evidence is restricted and encompasses various types of rhinitis, with no major safety concerns but potential complications. Short-term results are promising, but ambiguity remains regarding its efficiency, particularly in identifying the most suitable patient groups and the duration of therapeutic effects.

 

(B) The Condition, Current Treatments and Procedure

Rhinitis refers to inflammation and swelling of the mucous membrane inside the nose, typically lasting over twelve weeks. It is characterized by symptoms like itchiness, sneezing, and nasal congestion or discharge. It can be classified into three main types: infectious, allergic, and non-allergic, non-infectious rhinitis.

Treatment for rhinitis depends on the underlying cause and may encompass non-pharmacological approaches like trigger avoidance and environmental controls, pharmacological therapies like steroid nasal sprays and oral antihistamines, or surgical interventions like posterior nasal neurectomy.

The procedure for cryotherapy for chronic rhinitis involves administering local anesthesia. Insertion of a probe is done into the nasal cavity, and its balloon tip is positioned endoscopically in the posterior middle meatus. Upon contact with the targeted tissue over the branches of the posterior nasal nerve, nitrous oxide cryogen is discharged via the tip from the canister. This freezes the targeted mucosal tissue, intending to eradicate the posterior nasal nerve. Cryogen is typically delivered for 30 to 60 seconds. The contralateral side may be tackled similarly if necessary.

 

(C) Committee considerations

NICE executed a prompt assessment of the published literature to scrutinize the effectiveness and safety of cryotherapy for chronic rhinitis. This review encompassed a comprehensive search of seven sources, comprising 1 systematic review, 1 randomized controlled trial, 3 single-arm trials, 1 case-control study, and 1 analysis of the FDA's Manufacturer and User Facility Device Experience database. The committee discussed the evidence thoroughly. Key effectiveness outcomes considered by professional experts and the committee included betterment in quality of life, requisition for repeat procedures, and decrease in rhinitis symptoms.

Key safety outcomes incorporated infection, nasal dryness, dry eyes, bleeding, and pain. Although patient commentary was sought, none was received. Upon review of the evidence by the NICE committee, it was noted that cryotherapy for chronic rhinitis did not lead to a drop in concomitant medication usage. But, it was clarified that reducing medication usage was not the primary goal of the procedure, and it was suggested that the procedure might boost the effectiveness of medication.

Most studies reviewed only reported follow-up data within one year. Short-term evidence portrayed improvements in rhinitis quality of life and symptoms, although the evidence was restricted and incorporated individuals dealing with various types of rhinitis. It was suggested that cryotherapy might be more valuable for mitigating non-allergic rhinitis as opposed to allergic rhinitis owing to the greater availability of therapies for allergic rhinitis.

Additional investigation is prudent to better establish the usefulness of cryotherapy for chronic rhinitis, particularly regarding which patient groups would benefit most and the duration of treatment effects. It was noted that the procedure is typically performed alongside nasal endoscopy.