Episode # 3 • 17 Jan 2025
Optimizing CRS Outcomes with Posterior Nasal Nerve Ablation
Claims data suggest roughly one in three patients return after sinus surgery with persistent symptoms, and for many of them the complaint is drainage. On this episode of BackTable ENT & Allergy, host Dr. Ashley Agan welcomes Dr. Chris Davis, a comprehensive otolaryngologist in Birmingham, Alabama, whose practice is largely rhinology, to make the case that the persistent drainage after a technically perfect sinus surgery is a treatable problem rather than an acceptable residual. They discuss the anatomy and neuroimmune function of the posterior nasal nerve, how ablation may affect symptom scores and local inflammation, and the stepwise approach to patient selection and operative technique.
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Timestamps
00:00 - Introduction
05:12 - CRS as a Chronic Disease and the Patient Still Draining
09:31 - Posterior Nasal Nerve Anatomy and Type 2 Inflammation
12:42 - Sensory Nerves, TRP Receptors and Neuroimmunomodulation
17:27 - Placebo Questions and Three-Year Durability
19:34 - Screening With TNSS, SNOT-22 and NOSE
23:21 - Ipratropium Bromide Trials and Patient Selection
26:52 - Combining Ablation With Sinus Surgery
31:13 - Where to Treat and Adding the Swell Body
34:47 - Sphenopalatine Artery Risk and Staggered Treatment
37:34 - Coding and Reimbursement
42:21 - Temperature Control Versus Impedance Control
47:13 - Cryoablation, Device Design and Closing Thoughts
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More about this episode
The conversation follows the posterior nasal nerve from anatomy to the operating room. Dr. Davis describes a nerve that turned out to be a branching network rather than a single trunk, the early research on type 2 cytokine and sensory receptor changes in nasal secretions after ablation, and why he now thinks of the procedure as possible immune modulation rather than simply closing a tap. He then gets practical: the symptom scores he treats as nasal vital signs, the ipratropium bromide trial and what failing it really means, treating at the start of a sinus case while the field is dry, the staggered technique he credits for keeping delayed posterior bleeds rare, and the coding detail that makes combining the procedures viable. The episode closes on temperature control against impedance control, why he left cryoablation behind, and whether this nerve could one day keep patients off biologics.
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