What surgical options are available to alleviate severe or chronic postnasal drip in patients who have failed conservative management?

Surgical Options for Postnasal Drip

Surgery should only be considered for postnasal drip after complete failure of maximal medical therapy, which must include both nasal corticosteroids and nasal saline irrigations. 1

Medical Therapy Must Be Exhausted First

Before any surgical intervention is appropriate, patients must fail a comprehensive trial of medical management that includes ALL of the following 2, 1:

• Nasal corticosteroids for a minimum of 3 months 2
• Nasal saline irrigations to improve mucociliary clearance 1
• Antibiotics (minimum 3 weeks for chronic sinusitis, targeting H. influenzae, anaerobes, and S. pneumoniae) 2
• Oral antihistamine/decongestant combination (older-generation, minimum 3 weeks) 2
• Nasal decongestants (5 days maximum to avoid rhinitis medicamentosa) 2

Surgical Options When Medical Therapy Fails

1. Functional Endoscopic Sinus Surgery (FESS)

FESS is the primary surgical option for postnasal drip caused by chronic rhinosinusitis with documented anatomic obstruction that has failed medical therapy. 2

• Should only be performed when CT scan demonstrates disease amenable to surgical correction 2
• Requires correlation between symptoms, endoscopic findings, CT imaging, and failed medical response 2
• Image-guided CT scanning is essential for surgical planning, particularly when approaching the orbit, skull base, or frontal recess 2
• Effective for postnasal drip secondary to chronic sinusitis, nasal polyps, and fungal sinusitis 3, 4

2. Inferior Turbinate Reduction

Inferior turbinate reduction may be offered to patients with nasal airway obstruction and enlarged inferior turbinates who have failed medical management. 2

• This is an option (not a strong recommendation) based on observational studies 2
• Specific techniques include bipolar diathermy mucotomy (conchotomy) 5
• Results depend significantly on the etiology of rhinitis—outcomes are worst in patients with nonallergic rhinitis with eosinophilia syndrome (NARES) 5
• Critical pitfall: Staphylococcus aureus nasal colonization significantly worsens surgical outcomes and patient satisfaction 5

3. Septoplasty

Septoplasty should be considered when nasal septal deviation contributes to postnasal drip symptoms and medical therapy has failed. 2, 4

• Often performed in conjunction with FESS when anatomic obstruction is present 2
• Accounts for approximately 9% of postnasal drip cases requiring surgical intervention 4

4. Adenoidectomy

Adenoidectomy is appropriate for postnasal drip caused by adenoid hypertrophy, particularly in younger patients. 3, 4

• Adenoid vegetation accounts for 16-18% of postnasal drip syndrome cases 3, 4
• Should be confirmed with nasopharyngeal imaging or endoscopy before surgery 4

Critical Decision-Making Algorithm

When evaluating for surgery, assess the following in order 2:

1. Symptom-objective correlation: Do symptoms match endoscopic and CT findings?
2. Response to medical therapy: Has the patient completed ALL required medical treatments?
3. Anatomic factors: Is there correctable anatomic obstruction on CT?
4. Surgical candidacy: Are there contraindications to surgery or anesthesia?

Important Caveats and Pitfalls

• Many cases of chronic rhinosinusitis remain refractory even after endoscopic sinus surgery and benefit more from meticulous medical management 2
• Surgery carries risks including atrophic rhinitis, unnecessary cost, and surgical complications 2
• Overdiagnosis of sinusitis requiring surgery is a significant concern in clinical practice 1
• Radiofrequency turbinate surgery can rarely cause turbinate perforation leading to intractable postnasal drip, requiring revision surgery 6
• Preoperative discussion with otolaryngology regarding aspirin desensitization (especially before polypectomy), immunotherapy, and specimen cultures optimizes outcomes 2