Endoscopic Posterior Nasal Neurectomy Versus Radiofrequency Ablation in Refractory Allergic Rhinitis: A 2‐Year Randomized Controlled Trial of Clinical Outcomes and Immunomodulatory Responses

BACKGROUND: Endoscopic posterior nasal nerve (PNN) neurectomy and temperature-controlled radiofrequency ablation are validated interventions for medication-refractory allergic rhinitis (AR), but direct comparisons of their long-term efficacy, safety, and mechanisms remain lacking. METHODS: In this prospective, multicenter, randomized, patient-blinded study, 174 adults with moderate-to-severe persistent AR were allocated to PNN neurectomy (n = 89) or ablation (n = 85). The primary endpoint was the percentage of participants achieving the minimal clinically important difference (MCID) for the 24-h reflective total nasal symptom score (rTNSS) at 24 months. RESULTS: The rTNSS MCID responder rate at 24 months was 86.5% (95% confidence interval [CI], 80.0-95.0%) in the neurectomy group and 84.9% (95% CI, 78.0-94.0%) in the ablation group, with no significant between-group difference (p = 0.453). Both groups demonstrated substantial and parallel improvements in quality of life. Neurectomy provided greater and more durable control of rhinorrhea (1-24 months, all p < 0.05), nasal congestion (24 months, p < 0.001), and nasal itching (24 months, p = 0.046), alongside a greater reduction in unilateral nasal resistance (right side, p = 0.014). Both groups showed convergent systemic neuroimmune reprogramming at 1 year, with suppression of substance P, interleukin (IL)-31, IL-33, IL-4, IL-13, and IL-6, and increased transforming growth factor-β (TGF-β)and immunoglobulin G4 (IgG4). No serious adverse events occurred; mild transitory events were reported only with neurectomy (3.4%). CONCLUSION: Both techniques are effective and safe for refractory AR over 2 years. Although overall outcomes are comparable, neurectomy offers superior and sustained control of rhinorrhea, nasal congestion, and nasal itching. Treatment can be individualized based on symptom profile.