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Introduction
Directive Publications Dr.ahmet koçer maxillary nerve, innervates the lateral part of the ala nasi, whilst the anterior superior alveolar nerve innervates the columella (2). Clinically, nasal pain may be sharp or dull, paroxysmal or constant, short- or long-lasting, and superficial or deep in nature. It may also be accompanied by neuropathic symptoms, whether positive or negative. It may develop spontaneously or following trauma; it may begin immediately after the trauma, or it may develop weeks or even months after a mild trauma. The etiology of the idiopathic, non- traumatic form remains unclear; however, the failure of intranasal vasoconstrictors and anaesthetics to relieve the pain suggests that external nasal neuralgia involves a central pathophysiological process. According to a theory proposed regarding the etiology of centrally derived pain, stimulation of the peripheral branches of the trigeminal nerve leads to the activation of the caudal trigeminal nucleus in the brainstem, ultimately resulting in pain (3). In the idiopathic form, diagnostic investigations—including brain magnetic resonance imaging and computed tomography of the sinuses—usually yield negative results. In the treatment of this rare condition, very few patients respond to tricyclic antidepressants and gabapentinoids. Some patients, however, respond to local anaesthetic block of the external nasal nerve, sphenopalatine ganglion block and radiofrequency ablation (3,4). The differential diagnosis of these painful condition includes nasal septal anomalies, trigeminal neuralgia, trauma, rhinosinusitis, allergic reactions, ethmoid neuralgia, nasociliary neuralgia, intranasal tumours, Wegener’s granulomatosis, nasal polymorphic reticulosis, septal haematoma, or trigeminal autonomic cephalalgias (TACs) (5–7). In this study, we aimed to evaluate the effect of pulse radiofrequency (PRF) treatment on pain intensity and the dose of analgesics used in patients diagnosed with external nasal neuralgia. MATERIALS AND METHODS The study was conducted retrospectively at the Pain Clinic of ....... Hospital following approval by the Ethics Committee (No. …..-….). The study included patients who presented to the algology outpatient clinic between January 2018 and November 2025 with a diagnosis of external nasal neuralgia and a history of PRF)treatment. Data recorded during routine outpatient follow-ups of patients who underwent PRF treatment—including age, gender, pain location, the visual analogue scale (VAS) PRF as well as data on the doses of opioid and adjuvant medications used at baseline and weeks 4 and 12, were retrospectively retrieved and recorded. Procedure Patients were first given local anaesthesia using an intranasal lidocaine spray; patients who did not respond to oral local anaesthesia were included in the study. Prior to the application of PRF, an intravenous line was established and vital parameters (pulse, temperature, blood pressure, oxygen saturation) were monitored to confirm they were within optimal ranges. Subsequently, using a radiofrequency cannula, the external nasal nerve was entered at the junction of the os nasale and the lateral nasal cartilage, approximately 6–7 mm lateral to the nasal bridge (8), sensory feedback was used to confirm that the needle was precisely in the correct position, and 0.5 mL of 0.5% bupivacaine was injected. In patients who achieved a near-complete response to the local anaesthetic, 6-minute PRF was applied a few days later. Six patients received PRF to the external nasal nerve; one patient received PRF to both the sphenopalatine nerve and the external nasal nerve; and in one patient, due to the presence of both trigeminal V3 neuralgia and external nasal neuralgia, Gasser RF ablation and PRF to the external nasal nerve were performed. No adverse effects were observed in the patients either during or after the procedure. RESULTS At our clinic, a total of eight patients—50% female and 50% male—who had been diagnosed with external nasal neuralgia and received PRF treatment were evaluated. The mean age of the patients participating in the study was found to be 59.4 ± 14.1. Two patients with a history of trigeminal nevralgia in addition to external nasal nevralgia had previously undergone radiofrequency treatment of the Gasser ganglion in previous years, and neither patient had derived significant benefit from this treatment. In 4 of our patients, the pain was located along the right external nasal nerve tract; in 2, along the left external nasal nerve tract; in 1, along the left external nasal and right V3 nerve tracts; and in 1, in the bilateral paranasal region. The pain may be episodic, accompanied by a tingling sensation lasting up to 30 minutes, occurring two to three times a day; however, in some patients, there may be a constant burning sensation accompanied by mild to moderate pain. As in most cases reported in the literature (2,3), the pain was of a constant nature in five of our patients, whilst three presented with an intermittent course (9). The duration of pain in our patients ranged from seconds to 10 minutes. The pain in six of these patients was neuropathic in nature, whilst in two it was nociceptive. One patient diagnosed with migraine without aura experienced pain with allodynic features; furthermore, the presence of frequent migraine attacks supports a distinct process of central sensitisation (7). Page - 2Open Access, Volume 17 , 2026
Dr.ahmet koçer Directive Publications Page - 3Open Access, Volume 17 , 2026 The differential diagnosis of nasal pain may involve a wide range of etiologies, whether of local or central origin, and may be due to either spontaneous or traumatic causes. In our seven cases, an idiopathic etiology was considered the most likely cause, given the absence of a history of trauma and the normal results of the paranasal CT scan. Taking into account that there may be patients whose imaging remains normal following trauma, the failure of the pain to resolve with intranasal lidocaine application supported the view that the pain originated centrally rather than peripherally. One of our patients, however, had a burning pain that began several weeks after a trauma sustained three years prior, and unlike our other patients, this pain had responded to intranasal lidocaine. The mean VAS score was 8,16 ±1,18 pre-procedure, and was recorded as 1.96±1.12 at week 4 and 2.00±1.07 at week 12 post- procedure. A significant reduction in post-procedure VAS scores was observed (paired t-test, p<0.001). Furthermore, a reduction in analgesic dosage was achieved in 75% of patients, whilst in 25% of patients, medication could be discontinued entirely. Table 1.VAS score. Pre-procedure Week 4 Post-Procedure Week 12 Post-Procedure p value VAS 8,16 ±1,18 1.96±1.12 2.00±1.07 <0,001 VAS: visual analogue scale †Mean ± standard deviation. Table 2. Analgesic use. Medication Pre-procedural use, nPost-procedural use, nMcNemar p value Wilcoxon p value for dose change Comment Amitriptyline2 1 1.000 0.500 Discontinued in 1 patient; dose reduced in 1 patient Duloxetine 2 2 1.000 1.000 Number of users unchanged; dose reduced in 1 patient Gabapentin 2 2 1.000 0.500 Number of users unchanged; dose reduced in both patients Pregabalin 3 1 0.500 0.250 Discontinued in 2 patients; dose reduced in 1 patient Tramadol 1 0 1.000 1.000 Completely discontinued in the only user DISCUSSION AND CONCLUSION In line with the literature, our patients’ pain was confined to the cutaneous area innervated by the external nasal nerve; this distribution did not exhibit the typical topographical features of a non-traumatic neuralgia affecting a single terminal branch of the trigeminal nerve, such as the lacrimal, external nasal, infratrochlear or supraorbital nerves. Given the pain characteristics and the absence of autonomic symptoms in any of our patients, trigeminal autonomic cephalalgias and nasociliary neuralgia were also ruled out (9,10). In a series of four cases presented by Todd Rozen, two of the reported cases responded to pregabalin (675 mg daily) and memantine (30 mg daily) at doses exceeding the recommended levels, whilst the other two patients did not respond to the same medications. In one patient, they reported that local anaesthetic injections into the external nasal nerve provided short-term but significant relief, and that subsequent radiofrequency procedures on the sphenopalatine ganglion and maxillary nerve provided long-term pain control. In one patient, they reported that bilateral supratrochlear, infraorbital and maxillary nerve blocks provided temporary but significant relief, and that optimal pain control was achieved by adding sphenopalatine ganglion rhizolysis (2). The difference in our study is that in some of our patients, we achieved a response to amitriptyline, which we initiated as pre-procedural medical treatment, and achieved treatment success without performing nerve ablation. Similarly, in one patient, we achieved pain control by combining external nasal nerve treatment with sphenopalatine ganglion PRF therapy. In a study conducted by David G. Golding-Wood and colleagues, anterior ethmoidal nerve neurotomy was performed on two patients with post-traumatic external nasal neuralgia. Whilst the pain in both patients improved following surgery, one patient experienced permanent hypoesthesia, whilst the other developed temporary hypoesthesia around the nose
Dr.ahmet koçer Directive Publications (1). The difference in our treatment was that we did not perform nerve ablation, and consequently, no hypoesthesia was observed. Similarly to this study, a statistically significant difference in VAS scores was found in the long-term follow-up of our patients. The external nasal nerve block treatment administered by Héctor García-Moreno and colleagues to a 76-year-old patient with external nasal neuralgia and no history of trauma provided approximately three months of pain relief, independent of the duration of the local anaesthetic’s effect. They achieved pain palliation through repeated injections (10). In our study, similarly to this article, pain control was achieved with external nasal nerve blocks administered to both one patient with a history of trauma and seven patients with central idiopathic neuralgia. Unlike that study, we aimed to further prolong the pain-free period by applying PRF to the external nasal nerve. Marta Puma and colleagues, in a case involving a patient with post-traumatic persistent nasal pain who received topical steroid treatment in addition to systemic medication, achieved a significant reduction in pain, similar to our study (11). Onabotulinum toxin type A (BOTOX) was administered for the treatment of trigeminal neuralgia localised in the right external nasal region, as described in a case report published by Ngeow et al. (12). Although the patient had trigeminal neuralgia, the majority of the pain was localised in the external nasal region. Consequently, BOTOX was administered in high doses to the areas of intense pain; 60 units were injected into the right external nasal trigger point and 40 units into the right mental region, resulting in complete relief from pain in the right external nasal region for a period of one year (13). However, in another study, BOTOX treatment was attempted in two of the four reported cases of post-traumatic external nasal neuralgia, and no benefit was observed (14). In our study, pain relief was achieved in line with these reports; furthermore, PRF treatment carries a lower risk of side effects (such as difficulty swallowing, speaking and breathing, general weakness, ptosis, blurred vision, double vision, headache, temporary muscle weakness, etc.) compared to BOTOX applications. These cases highlight the difficulties in classifying and treating idiopathic non-traumatic nasal pain and support the notion that both neuropathic and non-neuropathic mechanisms may play a role in the persistence of the pain. Whether this pain represents a new entity or a variant of nasociliary neuralgia remains a matter of debate. In our view, external nasal neuralgia can be considered a specific form of neuralgia affecting one of the terminal branches of the trigeminal nerve. Due to the small number of cases reported in the literature, the treatment of such nasal pain syndromes is not standardised and must often be tailored to the individual. However, we believe that combined treatment approaches targeting different pain components are worth exploring, and that PRF treatment applied to the external nasal nerve as an invasive procedure for patients whose pain does not respond to medical treatments could be considered as an early therapeutic option. REFERENCES 1. Golding-Wood DG, Brookes GB. Post-traumatic external nasal neuralgia--an often missed cause of facial pain? Postgrad Med J. 1991 Jan;67(783):55-6. doi: 10.1136/ pgmj.67.783.55. PMID: 2057429; PMCID: PMC2398952. 2. Rozen T. Post-traumatic external nasal pain syndrome (a trigeminal based pain disorder). Headache. 2009;49:1223–8. Case reports of the only documented cases of post-traumatic external neuralgia with appropriate treatments. 3. Alvarez M, Montojo T, De la Casa B, Vela L, Pareja JA. Unilateral nasal pain with migraine features. Cephalalgia. 2013;33(12):1055–8. 4. Han SK, Shin YW, Kim WK. Anatomy of the external nasal nerve. Plast Reconstr Surg. 2004;114:1055-1059. 5. Ryan RE, Kern EB. Rhinologic causes of facial pain and headache.Headache. 1978;18(1):44–50. 6. Ryan RES, Ryan REJ. Headache of nasal origin. Headache.1979; 19(3): 173–9. 7. Cedaro de Mendoza J, Bussoloti-Filho I. Craniofacial pain and anatomical abnormalities of the nasal cavities. Braz J Otorhinolaryngol. 2005;71(4):526–34. 8. Mulero P, Guerrero AL, Pedraza M, Herrero-Velázquez S, de la Cruz C, Ruiz M, et al. Non-traumatic supraorbital neuralgia: a clinical study of 13 cases. Cephalalgia. (2012) 32:1150–3. doi: 10.1177/0333102412 459575 9. Pareja JA, Cuadrado ML, Porta-Estessam J, Fernandez- de-las-Penas C, Gili P, Caminero AB, et al. Idiopathic ophthalmodynia and idiopathic rhinalgia: two topographic facial pain syndromes. Headache. 2010;50:1286–95. 10. Garcia-Moreno H, Aledo-Serrano A, Gimeno-Hernandez J, Cuadrado ML. External nasal neuralgia: a neuropathic pain within the territory of the external nasal nerve. Headache. 2015;55:1259– 62. Relatively recent case report of idiopathic nasal neuralgia. Page - 4Open Access, Volume 17 , 2026
Dr.ahmet koçer Directive Publications Page - 5Open Access, Volume 17 , 2026 11. Puma M, Petolicchio B, Viganò A, Maestrini I, Di Piero V. A Case of Post-traumatic Persistent Nasal Pain. Front Neurol. 2020 Feb 3;10:1409. doi: 10.3389/ fneur.2019.01409. Erratum in: Front Neurol. 2021 Jan 05;11:636634. doi: 10.3389/fneur.2020.636634. PMID: 32116984; PMCID: PMC7009175. 12. Cheong Ngeow W, Rekha N. Injection of botulinum toxin type A (Botox) into trigger zone of trigeminal neuralgia as a means to control pain. Oral Surg Oral Med Oral Pathol Oral Radiol.2010;109(3):e47–50. 13. Nierenburg H, Morris MS. External Nasal Neuralgia: an Update. Curr Pain Headache Rep. 2017 Sep 13;21(11):44. doi: 10.1007/s11916-017-0645-5. PMID: 28900824. 14. Blumenfeld A, Ashkenazi A, Napchan U, Bender SD, Klein BC, Berliner R, et al. Expert consensus recommendations for the performance of peripheral nerve blocks for headaches-a narrative review. Headache. 2013;53:437– 66.
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