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BackTable / ENT / Article
The Emerging Role of Posterior Nasal Nerve Ablation in Obstructive Sleep Apnea
Lilyrose Bahrabadi • Updated May 28, 2025 • 54 hits
Posterior nasal nerve (PNN) ablation is a minimally invasive procedure that is used to treat chronic rhinitis – particularly when symptoms such as rhinorrhea, nasal congestion, and sneezing are not well controlled with medications. It functions by targeting the posterior nasal nerve in the sphenopalatine foramen, using either cryotherapy or radiofrequency to ablate the nerve. This procedure has emerged as a promising adjunctive therapy for obstructive sleep apnea (OSA) patients, offering a minimally invasive approach to reducing nasal congestion and improving sleep quality. But how exactly does this technology work, and what impact does it have on patients struggling with unresolved OSA? As the clinical potential of PNN ablation continues to unfold, otolaryngologists Dr. Matheny and Dr. Ananth explain how they have seen the procedure effectively modulate autonomic control of mucus production and nasal airflow resistance, two factors that undermine CPAP adherence and exacerbate OSA symptoms. As the procedure becomes more widespread, explore how PNN ablation can be effectively integrated into your therapeutic arsenal.
This article explores the leading PNN technologies, including ClariFix cryotherapy and radiofrequency based therapies such as RhinAer and NEUROMARK, all of which have demonstrated notable efficacy in enhancing nasal airflow and reducing post nasal drainage.
This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable ENT Brief
• CPAP is often prescribed as the default treatment for OSA, despite the treatment's high rate of abandonment. It has been shown that the vast majority of OSA patients will stop using CPAP within 90 days due to discomfort and generally poor adherence.
• Dr. Matheny and Dr. Ananth emphasize the importance behind a multifaceted approach to OSA that includes nasal interventions and surgical alternatives, such as hypoglossal nerve stimulation, to offer more sustainable, patient-centered solutions.
• Posterior nasal nerve (PNN) ablation reduces nasal congestion by halting the autonomic signalling, driving mucus production in the nose that often contributes to sleep disruption in OSA. By improving nasal airflow, these interventions can be used as adjuncts to other OSA treatments, such as CPAP, to provide a more effective sleep apnea relief.
• Posterior nasal nerve ablation technologies include cryotherapy (ClariFix) and radiofrequency ablation (RhinAer or NEUROMARK), among others.
• Both Dr. Matheny and Dr. Ananth prefer the RhinAer technology, as it can be used to treat both turbinates and septal swell bodies. This addresses both mechanical obstruction and autonomic mucus production. Both have observed faster patient recovery times, minimal complications, and high satisfaction rates when using RhinAer in their practices.
• Small increases in the nasal airway can lead to disproportionately large improvements in airflow due to the fourth power radius relationship shown in Poiseuille’s law.
Table of Contents
(1) The Burden of OSA & Challenges with CPAP
(2) Posterior Nasal Nerve Ablation in OSA
(3) The Science Behind Posterior Nasal Nerve Ablation in OSA
The Burden of OSA & Challenges with CPAP
The burden of untreated obstructive sleep apnea (OSA) is exceptionally profound and the reliance on CPAP as a singular solution contributes to high rates of non-compliance and therapy abandonment within just 90 days of use. OSA treatments have had to broaden in response to this non-compliance, resulting in a variety of options, including nasal interventions and surgical alternatives – like hypoglossal nerve stimulation – rather than solely relying on CPAP.
Otolaryngologists expertise in upper airway physiology and the uniquely multifactorial nature of OSA make them ideally positioned to direct multi-specialty solutions to OSA. Using nasal interventions and surgical alternatives as adjuncts to CPAP therapy addresses both anatomical and functional contributors to OSA, improving patient adherence and long term outcomes.
[Dr. Ashwin Ananth]
OSA is a field with a fellowship behind it that's a sleep fellowship. Even with the sleep fellowship, OSA is going to be 90%-plus of what a sleep physician is treating. OSA is an upper airway disorder. Your brain is telling you to breathe, your diaphragm is trying to bring air into your lungs and there's obstruction in the upper airway. We're biased, we're all biased. Nobody knows that better than us, than knows the pharynx, the larynx, and the upper airway. It's our wheelhouse. Understanding that you can impact an OSA patient more meaningfully than a lot of physicians who do sleep medicine can is really important.
I feel that all otolaryngologists, whether they want to be or not, are probably really good sleep doctors for OSA. Another thing I'll say, and you highlighted it with the Inspire comment, is that when a patient sees a sleep physician who is not a surgeon, there's really only one answer. That answer is CPAP. A lot of patients will pick up on that. Eventually, the patient says, the CPAP's really bothering me, I don't like it, it's blowing in my face, it's waking me up, I hate it. The doctor says, you need to wear your CPAP, or we'll try on BiPAP, or we'll try a different mask.
Then the patient comes back and maybe it's a little better, maybe it's not. The doctor says, you really need to wear it, you're going to die if you don't wear it. At some point, that patient will become cognizant of the fact that there's only one tool in the toolbox there. That patient will put the CPAP under their bed, or they'll get rid of it, or their insurance will reclaim it because they're not using it. What I've seen in my couple years of practice is that there are so many of those people out there that have put OSA treatment, they've forgotten about it, and they're sleeping in a different room as their bed partner, or they're suffering a developed atrial fibrillation.
[Dr. Keith Matheny]
Drives me crazy, because I see this, snoring is a frequent topic of comedy routines. It's not funny. This is the most severe disease that an otolaryngologist takes care of, except for head and neck cancer. We're only really treating about 1% of patients longer than 90 days that have OSA.
[Dr. Ashley Agan]
1%? One?
[Dr. Keith Matheny]
A quarter of this planet, 25% of this planet is walking around with diagnosable OSA. I'm just talking about OSA here. Of that, even in the Western world, we have only diagnosed 10% of people that have OSA. Of that 10%, we're only treating 10% longer than 90 days. Yes, Ashley, if my math is right, it's 1%. Imagine if we were treating 1% of head and neck cancers. That's what we're doing with this, and it's just as morbid and it's just as fatal. Maybe not as quick as a bad laryngeal squamous cell, but just as fatal eventually.
[Dr. Ashwin Ananth]
What I've seen with the marketing campaign with hypoglossal nerve stimulation, namely Inspire, the patients see a commercial and they see, oh, some joke about snoring at the dinner table and then click a button, OSA is gone, no mask, no hose, just sleep. These people come out of the woodwork and I've been seeing patients who said, my last sleep study was 20 years ago. When's the last time you wore a CPAP? 19 years ago. What have you been doing since then? I've been sleeping in a recliner in a separate room and I'm miserable and I take a nap every day for four hours, and my boss is about to lay me off, or something like that.
The burden of untreated OSA, as Keith is referring to, is absolutely enormous. In a similar way to bariatric surgery, I heard a bariatric surgeon tell me one time, we're not going to operate our way out of the obesity epidemic. In the same way, I don't think we're going to operate ourselves out of the OSA epidemic, but this is where the role of the nose is huge because we can recognize that and that may be the barrier to treatment that can get a lot of patients back in the game of being treated with their OSA. Whether that be getting back on CPAP or whether that be a bridge to other CPAP alternatives, it's additive therapy and again, a perfect correlate with head and neck cancer.
I'm not trying to say that OSA is cancer, but the way that we learned how to treat head and neck cancer was if you have a head and neck cancer, we diagnose it and we treat it and if it recurs or you get a second one, then we don't say, hey, we gave it a shot, sorry, you're dead. We say, we'll do salvage therapy or let's do something else. That's the way and even it parallels on my notes. This is my treatment history for OSA with this patient. The way I say it is if you're going to be on CPAP, we can dial up the CPAP and we can blow it away. If we're going to do something else, then we're going to get it as best as we can and it might not be one thing. It might be a treatment course.
[Dr. Keith Matheny]
Multi-level, right?
[Dr. Ashwin Ananth]
Yes, multi-level. Then the nose will only help whatever else we decide to do, if anything.
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Posterior Nasal Nerve Ablation in OSA
Posterior nasal nerve (PNN) ablation has shown promise as an effective treatment for improving sleep quality in patients with OSA by addressing nasal congestion and obstruction, both of which exacerbate the condition. Two novel devices for PNN include the ClariFix cryotherapy and the RhinAer and NEUROMARK radiofrequency treatments. Some physicians have found that treating OSA with PNN ablation not only enhances airflow by reducing congestion in the nasal passages but also addresses the autonomic control of mucus production in turbinates, which can contribute to discomfort and poor sleep.
Out of the available treatments, Dr. Ananth and Dr. Matheny both favor RhinAer due to its ability to anatomically treat both turbinates and septal swell bodies, while also still utilizing PNN ablation to provide a more comprehensive approach to combating nasal obstruction. The benefits of this multifaceted approach not only include improved airflow but also improved patient satisfaction due to the quick recovery times and minimal complication risk. Although RhinAer is typically the preferred form of therapy, data from all three devices have shown significant improvements in patient’s perceived nasal airflow and sleep quality, supporting its role as an adjunctive therapy in OSA management.
[Dr. Ashley Agan]
That one's interesting to me, doing a posterior nasal nerve ablation would help with sleep quality, like I suppose as we talk it through and just talk about it.
[Dr. Keith Matheny]
The data is good. All three technologies that are out there, of course, there's one cryotherapy, the ClariFix, that's now Stryker, was a company called Arrinex. Then there's two radio frequency options, the hair and medical one called the RhinAer, and the Neurent, a medical device, the NEUROMARK, which I personally have not used but many of our colleagues think highly of that product too. Even just treating the posterior nasal nerve, the data is good that it improves sleep quality.
What I do in my practice, and Ashwin, I love your thoughts, and Ashley, you too, I choose the RhinAer more often than not because I can also use that to treat the turbinates and treat the septal swell body. I love the option of treating the congestion, the actual mechanical obstruction in addition to the autonomic innervation of the turbinate making the snot, making the mucus. Others may feel differently that they get good enough results just with treating the PNN.
[Dr. Ashwin Ananth]
RhinAer, as far as PNN treatments and chronic rhinitis treatments, allergic or non-allergic rhinitis, the hair and medical, the RhinAer is my favorite. I was very, very, very, very skeptical at the beginning because I hadn't done it in residency, I hadn't done it in fellowship. In residency and fellowship, I did ClariFix. As a counterpart to the VivAer, we did full rhinoplasties or functional rhinoplasties a lot.
I had no experience with NEUROMARK or RhinAer or VivAer coming into practice. It's funny, my local rep reminds me, the first time I ever did one, I was pretty nervous. I said, look, I just don't want to kill this person. He laughed at me. Now I love offering it because it's so safe and it's very effective. The effectiveness has blown me away because of how easy it is to do.
[Dr. Keith Matheny]
It's quick.
[Dr. Ashwin Ananth]
And how happy the patients are, it has helped me not think twice about offering. The reimbursement was great, now it's good, which only helps. The ease of recovery for the patient, they get up out of the chair and they walk out and they drive home. The effectiveness, which has been very favorable, and the safety, knock on wood, I haven't had a single serious complication, has been fantastic. In terms of PNN treatment, I totally agree.
I think it has something to do with post-nasal drip and retained secretions in the tongue base or the pharynx of something that triggers some kind of cough or gag reflex and wakes you up. That's my personal theory on why the PNN treatment helps for that. You're also doing the turbinates in the swell body also. Maybe it's something about nasal flow and airway obstruction coupled with that. I haven't done PNN treatments alone and I haven't done anything other than the RhinAer in practice other than like one NEUROMARK.
[Dr. Keith Matheny]
In fairness to the other two, I prefer the RhinAer because of being able to treat three spots, but the data is good on a patient's perception of airflow. I know with the ClariFix and I would presume with the NEUROMARK too.
[Dr. Ashley Agan]
That's the outcome that they're looking at is nasal airway scores.
[Dr. Keith Matheny]
Exactly.
[Dr. Ashley Agan]
Do they look asleep?
[Dr. Keith Matheny]
Whether it's SNOT-22 or other TNSS, whatever, patients feel like they're moving more air with all, and that's got to be helpful for OSA. It's got to be helpful.
The Science Behind Posterior Nasal Nerve Ablation in OSA
When understanding treatments for nasal obstruction, it is critical to understand the science behind nasal airflow and its impact on OSA. Although PNN ablation leads to a small increase in localized nasal passage size, the combined effect of dilation throughout the airway results in a significant reduction in resistance and airflow. Slight improvements in the nasal passage, whether through radiofrequency treatments or surgical interventions, can often improve airflow above the critical threshold, alleviating much of the patient’s perception of obstruction. Relatively minor, office based interventions like these can provide substantial clinical benefits and offer patients immediate relief from nasal obstructions and improvements in their OSA management. By operating in the interplay of nasal anatomy and airflow dynamics, clinicians can make more informed decisions on which treatments to use, maximizing therapeutic outcomes in OSA care.
[Dr. Ashwin Ananth]
I'm going to bust out some physics. The radius to the fourth power. The radius to the fourth power, what that means to me is that a tiny increase in the nasal airway will impact flow exponentially. My correlate is subglottic stenosis and that classification of subglottic stenosis where it's like the child has no symptoms, the child has no symptoms, and then all of a sudden the child has stridor and problems.
I think the nose is the same way. You have a threshold at which you perceive nasal obstruction, even though there is some flow. If you get above that threshold, then whether that be with just a tiny little radiofrequency or that be with bony surgery or mucosal with real operative surgery like we do, you get above that threshold and the flow gets to a point where the patient doesn't perceive nasal obstruction anymore. That's my physics theory.
[Dr. Keith Matheny]
I'm glad you brought that up. That's not too scary physics. I can understand that at least. I say that 10 times a day, if I give you 2 millimeters, you're going to feel like I opened your airway 16 millimeters. Patients really do. That's what's been fun for me to see the evolution. You guys trained when there already were office procedures, but I didn't. Seeing that really come to fruition in 2011, the difference when patients could tell us in the chair, doc, whatever you just did, even if I ballooned a maxillary sinus or whatever, seeing that Bernoulli principle in real life, the second I took the balloon out, say, whatever you just did, I can breathe better.
It's like you're holding a fan up to my nose. To the point, I used to think it was a placebo or it was the Afrin. We now know, no, that's actually true. We're taking a 2-millimeter os and making it 6 millimeters, and the patient feels that right away. I think it's the same with these treatments of the turbinates and the swell body.
Podcast Contributors
Cite This Podcast
BackTable, LLC (Producer). (2025, February 11). Ep. 210 – Rethinking OSA: Role of the Nose [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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