Surgical Management of Non-Allergic Rhinitis-An EAACI Task Force Position Paper

Non-allergic rhinitis is a frequent yet underdiagnosed cause of chronic nasal symptoms, including nasal congestion, rhinorrhoea, and upper airway hyperreactivity. Its pathophysiology involves neurogenic dysregulation, leading to excessive mucus production and vasodilation. While medical therapy remains first-line, some patients experience persistent symptoms requiring surgical intervention. This review outlines key surgical options for refractory non-allergic rhinitis: inferior turbinate (IT) reduction, vidian neurectomy, and posterior nasal nerve (PNN) ablation. IT reduction-performed using cold instruments, radiofrequency, laser, coblation, or microdebrider-remains the cornerstone treatment for nasal obstruction, offering durable symptom relief with low complication rates. Vidian neurectomy effectively reduces rhinorrhoea but carries risks of ocular dryness and transient facial numbness, limiting its indication to severe, refractory cases. PNN interventions, including cryotherapy, cold-instrument techniques, and radiofrequency, provide a minimally invasive, outpatient alternative that selectively targets nasal parasympathetic and sensory fibers while sparing lacrimal innervation, yielding significant and lasting symptom improvement. Surgical management of non-allergic rhinitis is effective and safe when tailored to symptom profile, anatomy, and prior medical treatment response. Advances in endoscopic and minimally invasive approaches have reduced complications, establishing these procedures as integral options in comprehensive non-allergic rhinitis care.