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BackTable / ENT / Article
In-Office Procedures for Chronic Rhinitis: ClariFix, Rhinaer or Neurent?
Iman Iqbal • Updated Feb 28, 2025 • 38 hits
In-office procedures have transformed the management of chronic rhinitis, offering effective, minimally invasive alternatives for patients who struggle with persistent nasal congestion. Various devices now target the posterior nasal nerve to reduce symptoms, each using different technologies to optimize patient outcomes. However, these advancements come with their own challenges, from anatomical variations affecting procedural efficacy to post-procedure complications that require careful management. Advancements in anesthesia protocols, procedural techniques, and post-operative care have streamlined these interventions, improving patient experience while minimizing complications.
This article provides an overview of in-office chronic rhinitis treatments, covering device selection, anatomical considerations, and best practices for patient management. This article features excerpts from the BackTable ENT Podcast with otolaryngologist, Dr. Omar Ahmed. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable ENT Brief
• ClariFix, RhinAer, and Neurent each use distinct approaches to target the posterior nasal nerve, with different benefits and limitations. ClariFix uses cryotherapy to target the posterior nasal nerve, while RhinAer and Neurent use radiofrequency ablation with varying precision.
• Procedures are typically performed using topical anesthesia, with lidocaine spray and tetracaine-soaked pledgets, avoiding injections unless necessary.
• Structural deviations, such as septal spurs and severe septal deviations, may require additional interventions like in-clinic septoplasty or balloon dilation.
• Initial ablation techniques focused on a few sites near the middle meatus but have since expanded to multiple ablation points for improved efficacy.
• Expanded treatment protocols have increased success rates to 90%, though some patients experience symptom recurrence, likely due to nerve regeneration.
• Patients should expect congestion and swelling for about a week, with nasal rinses commonly recommended to aid healing.
• While major bleeding is rare (<2% incidence), patients on anticoagulants may need to pause stronger medications before and after the procedure.
• Symptom relief typically lasts at least two years, with some patients maintaining benefits beyond three years, though further research is needed to assess long-term nerve regeneration.
Table of Contents
(1) Comparing In-Office Treatments for Chronic Rhinitis: ClariFix, RhinAer & Neurent
(2) Anesthesia Protocol for In-Office Rhinitis Procedures
(3) Navigating Challenging Nasal Anatomy
(4) Post-Procedure Care & Risk Management
Comparing In-Office Treatments for Chronic Rhinitis: ClariFix, RhinAer & Neurent
Multiple in-office devices are now available for the treatment of chronic rhinitis, each utilizing different techniques to target the posterior nasal nerve. ClariFix, the first device to receive FDA approval in 2017, uses cryotherapy to freeze the nerve, with reported success rates ranging from 65% to 90%. RhinAer, introduced in 2019, employs temperature-controlled radiofrequency ablation at 60°C, providing precise treatment while preserving surrounding tissue. Unlike ClariFix, RhinAer also addresses septal and vestibular swell bodies, key contributors to nasal congestion. The newest device, Neurent, also uses radiofrequency ablation but takes a broader approach, deploying two leaflets to reach the posterior nasal nerves. While Neurent offers a simple one-time treatment, it does not target septal swell bodies or turbinates as effectively as RhinAer according to Dr. Ahmed.
Comparative studies suggest that ClariFix and RhinAer achieve similar efficacy, though ClariFix has been associated with a higher incidence of headaches. Given their targeted mechanisms, these procedures are ideal for patients who have not responded to or cannot tolerate medical therapy.
[Dr. Ashley Agan]
Can you give us an overview on the different devices that are out there for the in-office procedures? Then I would like to then get into the more specifics of the RhinAer device.
[Dr. Omar Ahmed]
Yes. Right now there's three devices in the market. The first device that was FDA-approved is ClariFix. I think it was FDA-approved in 2017. It was the first to the market. It uses cryotherapy ablation, so it's almost freezing the posterior nasal nerves. There's great data for it. It's successful. The data rating is anywhere from 65% to I think 90% success rate in terms of responder rate. I think the second one that came out was 2019 that was FDA-approved was the RhinAer. This uses a temperature-controlled radiofrequency ablation of the posterior nasal nerve and it heats it to 60 degrees Celsius.
It's just the right temperature where you're not burning the surrounding tissue and damaging the surrounding tissue. That device, again, great success. A lot of my research has been done using that device. The nice advantage of this device is that it can really target the septal swell bodies, which are very involved in nasal congestion, which we traditionally did not think of. It can be used to treat the vestibular swell body as well. As our understanding of the posterior nasal nerves is changing, there are many more areas that are hard to reach. With this device, you can actually get access to those areas because the tip of the stylus is much narrower and smaller, it's more focused.
You can actually get behind the middle turbinate. You can get in these tight areas, which you couldn't get before. That's the second device. The third device that was just FDA-approved is the Neurent. This uses a radiofrequency ablation, similar to Aerin. What this does is, again, I think a 90-second treatment that basically is a shotgun approach. You basically have these two leaflets and you basically have one leaflet that goes behind the middle turbinate attachment and another leaflet that goes in front of the middle turbinate attachment. The idea is targeting all the posterior nasal nerves.
I've not had as much experience using that. I have performed some and now we're involved in the clinical trial for it. The advantage is it's just like an easy one-time shotgun approach. The disadvantage is you can't treat the septal swell bodies or the turbinates or vestibular swell bodies, which you can with RhinAer. In terms of efficacy, we actually did an indirect comparison paper and we published this in IFAR where we looked at using what's called a butcher coefficient. You can do an indirect comparison if the clinical trials were performed in a very similar manner.
We looked at both ClariFix and RhinAer and we found them to be equally effective. The one thing that at least we've looked at with our own data is the amount of headaches with ClariFix. Actually, one out of two of our patients that we've done ClariFix, we've done about 90 ClariFixes now in our group and one out of two have had a major headache. That lasts at least an hour. It's like an ice cream headache, which you don't get typically with the other devices.
[Dr. Gopi Shah]
I think that's one of the side effects that I think always makes me nervous about using the cryotherapy as well. When you are thinking about who's the best candidate for the procedure, take me through your thought process on that.
[Dr. Omar Ahmed]
I think any patient that has tried medication and it fails, or they just can't tolerate the medication. Sometimes people say with Fluticasone or some Ipertropium, it really burns their nose, they can't do it. Patients who've tried medication that just can't do and they want some type of relief, I think any patient is really a candidate, anyone from 18 and above. I've performed it on patients that were 92 years old and I've performed it on patients who are 25 years old. I have a wide range. Basically, anyone who doesn't necessarily want long-term treatment and wants more of a quick fix.
I think anyone who's interested, I think, is a candidate. Patients who are super anxious and you know it's going to be difficult to do an in-office procedure, those are patients I typically will shy away from or at least say, "Hey, we can do this in the OR in conjunction with another procedure."
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Anesthesia Protocol for In-Office Rhinitis Procedures
The anesthesia protocol for in-office nasal procedures begins with giving patients an initial spray of lidocaine with Afrin. Following this, nasal pledgets soaked in 6% tetracaine are placed in two key areas: one in the middle meatus and one along the inferior turbinate. Patients then wait for 10 to 15 minutes before undergoing the procedure. The procedure itself takes less than 10 minutes and is performed using only topical anesthesia, avoiding injections. Injections were once used to improve radiofrequency ablation conductivity, but natural tissue fluid has been found to provide adequate conduction. Injections may also cause unnecessary bleeding. Most patients tolerate the procedure well without additional sedation. Sometimes, patients may be given sedatives like Valium or Triazolam if they have anxiety about the procedure.
[Dr. Ashley Agan]
We would love to hear your anesthesia protocol. I'm just talking about how you get patients comfortable and prepared for the procedure in the office.
[Dr. Omar Ahmed]
It actually works really well on my clinic days to do these procedures. I block off the 30-minute slot. What I do is traditionally, as soon as they walk in, they fill out surveys. They get sprayed with Lidocaine with Afrin. Then I walk into the room right after they've been sprayed. I put two pledgets on each side. I have one pledget that's cut in half, and I actually take that pledget and put it in with a bayonet initially. Then I take a Freer and slide it into the middle meatus. It's 6% tetracaine. It's really hard to actually get it into the middle meatus, but that's the reason that you need to put the pledget in to get a good position. The second pledget goes along the inferior turbinate.
I do it on both sides. Again, really important to put the pledget in that middle meatus region and see it go in. Once I do that, I let them sit for 15 minutes, see my next patient, then walk back and do the procedure. The procedure takes on average less than 10 minutes. In terms of clinic flow, it's just very efficient. Doesn't take up that much time, because while they're getting anesthetized, you are seeing another patient. They're sitting there doing their red cap surveys.
[Dr. Gopi Shah]
That's great. It's just a nasal pledget with Afrin and Lido, and that's it?
[Dr. Omar Ahmed]
No. I spray them first with Afrin and Lido to help decongest their nose, my nurse does that. Then I come in and put pledgets in the nose with 6% tetracaine.
[Dr. Gopi Shah]
You let those sit, but once you remove those, you don't do an injection in that area. It's just all topical.
[Dr. Omar Ahmed]
All topical. I used to. It's interesting. One of the concepts with radiofrequency ablation is it conducts better through liquid. I used to always inject, but I think there's enough edema and fluid in the tissue itself that it doesn't need it. I don't inject. Part of the reason why I don't inject is because sometimes with the injection, the area gets bloody for me. I record my cases, so I like it when it's bloodless.
[Dr. Gopi Shah]
Yes, of course. How long do you leave the pledgets on for?
[Dr. Omar Ahmed]
10 to 15 minutes.
[Dr. Gopi Shah]
Do you have patients that want to take some sort of benzo, like a Valium or a Triazolam, and do you find that that's necessary?
[Dr. Omar Ahmed]
Very rarely. I'd say maybe three times a year, I'll have some patients that are super anxious that need it, but for the majority of patients, I don't. I just do it, and they're usually fine.
Navigating Challenging Nasal Anatomy
In cases of severe global septal deviation where scope access is obstructed, alternative interventions are often necessary. However, for more localized issues such as septal spurs, targeted in-clinic septoplasty can be an effective solution. Additionally, balloon dilation may help improve access, though it can sometimes shift the deviation to the opposite side, requiring further consideration.
These anatomical challenges have influenced the evolution of treatment algorithms for posterior nasal nerve ablation. Initially, ablation was performed at only a few sites near the middle meatus, yielding moderate success rates. However, variations in the sphenopalatine foramen and middle turbinate attachment led to a reassessment of treatment strategies. As a result, a more comprehensive approach was developed, incorporating multiple ablation points—including sites in front of and behind the middle turbinate, near the Eustachian tube, along the inferior turbinate, and at the mulberry tip. By expanding the number of treatment sites, success rates have increased to approximately 90% according to Dr. Ahmed. To maximize efficacy, clinicians now perform 13–14 ablations per side, slightly exceeding standard protocol limits by carefully adjusting treatment duration at each site.
Despite these advancements, symptom recurrence remains a challenge for some patients, suggesting the possibility of unidentified nerve pathways or nerve regrowth. Long-term data indicate that most patients experience sustained relief for at least two years, with some maintaining benefits beyond three years. While the exact mechanism underlying symptom recurrence is not yet fully understood, current evidence suggests that the procedure resets nerve function rather than permanently eliminating it. Further research is needed to clarify long-term outcomes and determine whether nerve regeneration plays a role in symptom recurrence.
[Dr. Gopi Shah]
Talk to me a little bit about difficult anatomy. I think of deviated septums, I think of really huge body turbinates. How do you manage some of that anatomy in the clinic, and when are you like, "You now what, we got to go do some other things first before we can get access to where we need to be?"
[Dr. Omar Ahmed]
I think a global deviation that's severe on a septum and that's very challenging to get around, but they're patients-- For those patients, if I see and there's no room to get a scope even into that region, then I will usually try to shy away from an in-office procedure for those patients. There are some patients that have a septal spur. Even if the spur is right at the treatment site, I think for those patients, you can actually do something. I actually have done targeted septoplasty in clinic where I'll actually inject that part of the septum and I'll actually raise little submucosal flaps in those regions.
Then bite off that region and then lay the flaps back on, and then I'll do the procedure. There's also the airway balloon by Clarent, which you can use, which I think is useful. It does cause a deviation to the other side sometimes, but I think you can use that as well.
[Dr. Gopi Shah]
In terms of actual stylet placement, when you're doing the posterior nerve ablation, where exactly and how many-- are you marching down to the floor of the nose posteriorly? Where are you putting everything, and how many of these areas do you ablate?
[Dr. Omar Ahmed]
If you look at our treatment algorithm, it's changed over the years. When I first started doing this, we were doing three, four treatments in the posterior nasal nerve region and basically the middle meatus. We looked at right in front of the middle turbine attachment. We found our success rates were about 60% when we did that. We looked at our data. We actually ended up getting CT scans on a lot of patients. For some of those patients that failed, we did posterior nasal neurectomy, and the video neurectomy. What we found is that some patients had a middle turbinate that was very anterior in relationship to the sphenopalatine foramen.
I know this is complicated, but a lot of the main branches of the posterior nasal nerve were coming out of the sphenopalatine foramen. In some patients, the middle turbinate attachment, the lateral lamella of the middle turbinate is much more anterior. I think in those patients, if you just treat in front of the middle turbinate, you're going to miss a lot of posterior nasal nerves, different branches of the parasympathetics. We actually changed our algorithm and we saw a significant increase in our success rates, our responding rates from 60-something percent to 90%. We actually published that in IFAR as well.
My algorithm is because of this new knowledge, non-overlapping sites, I'll do about four to five treatments. I'll start right in front of the middle turbinate initially and I'll go as high as I can, as superior as I can. Then I'll do at least four to five treatments in that area. Then I march down and I actually go behind the middle turbinate attachment and will do one or two treatments. Then I'll go right in front of the Eustachian tube opening. Right before that towards the Eustachian tube, and there's a lot of parasympathetic nerves in that region, which I will treat, and I'll march my way down just behind the mulberry tip of this of the inferior turbinate and treat that region.
I think that region is really the highest yield area which we traditionally did not think of. Then I'll also do the turbinate, the mulberry because I think the mulberry does play a role in post-nasal drip. We're studying that as well. The turbinate is really large. I'll march along the inferior turbinate as well, all the way to the head of the inferior turbinate. Now if it's pure vasomotor, I don't feel the need to treat the head of the inferior turbinate or even treat the septal swell bodies. I will march along the region. Technically, you're allowed 11 treatments for each side.
I think I actually probably do 13 to 14 treatments. The way I get around it is for some of the treatments along the turbinate, I will actually just stop one-second shy of a lot of time and basically you don't use up a treatment when you do that. Probably 13 to 14 treatments on each side, just to be more comprehensive.
[Dr. Gopi Shah]
That's fascinating. I'm thinking about revisions. If you're doing that comprehensive treatment from the get-go now, do you find that you're doing less revisions because you really treated every possible place where you could have little nerve branches coming from, or if you did a revision, would you just do the same thing?
[Dr. Omar Ahmed]
Yes. I had one patient that, had ClariFix, had RhinAer, failed, and even had a posterior nasal neurectomy. Here I'm like, posterior nasal neurectomy's effectiveness is over 95%. It's really effective, but even in that, the patient failed. The patient was so desperate, I was like, "Okay, my last option is to do a video neurectomy." I did the video neurectomy and the patient has success. Clearly, even if you're as comprehensive as you can be, I think there's just some branches that we don't understand where they're even coming from and we're missing even as comprehensive as you can be.
[Dr. Gopi Shah]
Do we know if any of these nerves re-innervate or regrow? In terms of how long does this procedure last for, we said for the allergy patients, if we can get them a good one to two years, how do these procedures tend to last for and what do we think are the reasons for the return of symptoms?
[Dr. Omar Ahmed]
That's a very good question. We don't have a lot of data in terms of nerve regrowth. Clearly, we're not severing the nerve for these procedures. There's at least two-year data on success. I think there will be three-year data at some point. Clearly, it's beneficial. At least in my mind, I'm thinking we're resetting the nerve for these patients. We're not killing it. We're resetting the nerve. There's no data that's looked at, in live patients two years after what's happened. Ideally, a study where we look at patients that have success three years after and compare the nerve to patients who don't have success, is there a change?
I wanted to do some type of impedance testing, some type of way to test the electrical activity of the nerve. I'm trying to find someone good to collaborate, but we don't have data on it. Clearly, I think we are getting two years. I've had some patients with three years out and four years out that are great success. Clearly, we're resetting something. I don't know the exact mechanism of what's happening. No one does.
Post-Procedure Care & Risk Management
Post-procedure care for nasal nerve ablation focuses on managing expected discomfort and minimizing complications. Patients are advised to anticipate significant congestion and swelling, particularly if the entire turbinate is treated. In some cases, swelling can be severe enough to prompt early follow-up visits. While clinical data does not confirm a direct benefit, nasal irrigation is commonly recommended to help clear mucus and crusting. Additionally, patients are instructed to avoid forceful nose-blowing for the first two to three weeks to reduce the risk of complications.
Bleeding, pain, and discomfort are the most commonly reported post-procedural issues, but significant complications are rare. Given the bleeding risk, management of anticoagulation is an important consideration. For patients taking low-dose aspirin (81 mg), continuation is generally advised. However, stronger anticoagulants are typically held for a week before and after the procedure to minimize bleeding risks. While some practitioners may proceed without modifying anticoagulation, temporarily pausing these medications helps reduce post-procedural concerns and the likelihood of complications.
[Dr. Gopi Shah]
For your patients, after you've done the procedure, what are your post-procedure instructions? What complications are you on the lookout for?
[Dr. Omar Ahmed]
I always tell patients, "You're going to feel really congested like you had a really bad cold for a week. Just expect that you're going to feel miserable," especially if you treat the entire turbinate. It is really swollen. I've actually gotten the chance to see some of my patients two days post-treatment because they were so miserable, especially some of my VIP patients. You look in their nose, and it's pretty impressive how swollen it gets with any of the procedures in the nose. Even if you do a Celon turbinate reduction, it is so crusty and so swollen.
I tell my patient, "Your first week, you're miserable. Do your rinses." I actually tell patients to do their rinses just to help get some of the crusting and mucus out. There's no data on irrigation helps post-op recovery, but it just seems like we do tell all our patients are, "Get started on rinses." I do that. I tell my patients to really not blow their nose hard in that first few two to three weeks. If you look at the complication data from all the clinical trials, really, it's minor bleeding, pain, discomfort, those types of anxiety, things like that.
We have had the opportunity to do over 300 now. I think one of the dreaded complications, which I think can happen with any device that you use, is major epistaxis. I think we are treating the area of the posterior nasal nerve, which is right by the sphenopalatine artery and all its branches. At least in our data, none of our patients had immediate post-op bleeding. It was a small subset of less than 2% of patients, whether it was ClariFix, whether it was Neurent, or whether it was RhinAer, that had a bleed that required some type of surgical intervention.
Again, it's very rare. I've talked to people, though, that have done quite a few of these who have not run into that complication. Again, this is just my data set from doing-- mine and my colleagues from doing over 300 of these, and we did have a bleed rate of less than 2%. It's something to think about. I think the mechanism is probably-- it happens all at three weeks after the procedure. It seems to be, I would assume, probably some type of pseudoaneurysm of the vessels itself, the sphenopalatine branches, that rupture at three weeks. I don't know. Ashley, I know you do these procedures. Have you ever had an epistaxis?
[Dr. Ashley Agan]
No, I haven't. I heard other people talk about potentially having a massive nosebleed. I talk to patients about it and tell them, if something like that were to happen, they need to go to the emergency room, but I haven't experienced it personally.
[Dr. Omar Ahmed]
The thing is, anytime you operate, anytime you do functional endoscopic sinus surgery or any type of procedure in the nose, I think bleeding is a risk. I think as long as patients are aware of that, I have not had a patient turn away this procedure because of bleeding because anything we do can bleed, and even major bleeds, even after functional endoscopic sinus surgery. As long as patients are counseled on it, again, I don't think it'll deter patients away. It's very low risk. It doesn't matter what device you use. Most of the patients do really well. I think this has really changed the way I treat rhinitis patients.
[Dr. Ashley Agan]
Do you have your patients hold their anticoagulation for this procedure? Have them stay on it? What do you like to do?
[Dr. Omar Ahmed]
It depends on what anticoagulation they're on. Because of the bleeding risk, if it's Aspirin 81, I tell them to continue taking it. Anything more than that, I do like them to hold the medication. More so, I'm sure people do this procedure with patients on anticoagulation, and they're fine. For me, I'm just trying to avoid a lot of phone calls. I'm assuming the risk of bleeding increases. I usually have them hold it for a week.
[Dr. Ashley Agan]
Before, and then when do you let them restart it?
[Dr. Omar Ahmed]
Usually about a week.
Podcast Contributors
Dr. Omar Ahmed
Dr. Omar Ahmed is an Otolaryngologist and ENT Surgeon with Houston Methodist in Texas.
Dr. Ashley Agan
Dr. Ashley Agan is an otolaryngologist in Dallas, TX.
Dr. Gopi Shah
Dr. Gopi Shah is a pediatric otolaryngologist and the co-host of BackTable ENT.
Cite This Podcast
BackTable, LLC (Producer). (2023, December 12). Ep. 147 – Latest Innovations in Rhinitis Treatment: A Comprehensive Guide [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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