Endoscopic posterior nasal neurectomy: An alternative to
Toru Kikawada, MD
From the Nose and Sinus Surgicenter Nagoya, Nagoya, Japan; and ENT Surgicenter Hamamatsu, Hamamatsu, Japan.
Vidian neurectomy is a proven surgical treatment for the symptoms of allergic and nonallergic rhinitis.
However, complications such as dry eye, cheek and dental numbness, disturbance of eye movements,
and even blindness remain. I describe a method for endoscopic resection of the posterior superior and
inferior nasal nerves. My approach exposes postganglionic parasympathetic nerve ﬁbers (the posterior
superior nasal nerve) at the sphenopalatine foramen to allow resection of a segment of the nerve under
direct vision. The surgeon is able to control intraoperative bleeding without resection of the spheno-
palatine artery and achieve the effectiveness of vidian neurectomy without the complications.
© 2007 Elsevier Inc. All rights reserved.
Posterior nasal nerve;
The effectiveness of vidian neurectomy in relieving
the symptoms of allergic and nonallergic (vasomotor)
rhinitis is well established. Golding-Wood
the transantral vidian neurectomy in the 1960s. Since that
time, most vidian neurectomies have been performed
on the oriﬁce of the vidian canal on the posterior surface
of the pterygopalatine fossa.
Recently, Robinson and
described endoscopic vidian neurectomy on
the medial surface of the pterygopalatine fossa. Their
technique allows for identiﬁcation and resection of the
vidian nerve under direct vision. However, the risk of dry
Alternatives to vidian neurectomy have been reported. In
1983, Terao and coworkers
described cryosurgery on the
posterior superior nasal nerve at the sphenopalatine fora-
men. More recently, submucosal resection of the posterior
superior nasal nerve and the sphenopalatine artery using
ultrasonic coagulation has been reported.
bleeding from the sphenopalatine foramen is a risk in the
latter technique because the artery is not resected under
In this article, I describe an endoscopic technique that
exposes the posterior superior nasal nerve and the sphe-
nopalatine artery at the sphenopalatine foramen. This
technique allows the surgeon to remove a segment of the
posterior superior nasal nerve, to resect the posterior
inferior nasal nerve, and to control intraoperative bleed-
ing under direct vision.
The vidian nerve carries parasympathetic nerve ﬁbers from
the facial nerve to the sphenopalatine ganglion. At the
sphenopalatine ganglion, the parasympathetic ﬁbers syn-
apse. Postsynaptic parasympathetic ﬁbers form 3 branches
in the pterygopalatine fossa. These nerve branches innervate
the nasal mucosa as the nasal nerve, the lacrimal gland as
the lacrimal nerve, and the palate as the greater palatine
The parasympathetic nerve ﬁbers of the nose enter the
nose through the sphenopalatine foramen. These are called
the posterior superior nasal nerves (Figure 1). The posterior
superior nasal nerves divide further to become the lateral
and the medial posterior superior nasal nerves. The lateral
posterior superior nasal nerves innervate the superior, mid-
dle, and inferior conchae and the superior and middle me-
atus. Other parasympathetic nerve ﬁbers of the nose branch
off from the greater palatine nerve and enter the nasal cavity
through the canaliculi of the perpendicular plate of the
palatine bone as the posterior inferior nasal nerves. These
nerves innervate the inferior turbinate and the inferior me-
Address reprint requests and correspondence: Toru Kikawada, MD,
ENT Surgicenter Hamamatsu, 1696 Tenno-cho, Hamamatsu-shi, Shi-
zuoka-ken, 435-0052, Japan.
E-mail address: firstname.lastname@example.org.
1043-1810/$ -see front matter © 2007 Elsevier Inc. All rights reserved.
Operative Techniques in Otolaryngology (2007) 18, 297-301