Introduction: Refractory allergic rhinitis (RAR) encompasses distinct immune-inflammatory endotypes, notably neurogenic and eosinophilic phenotypes, which may differentially respond to surgical intervention such as posterior nasal neurectomy (PNN). Identifying prognostic biomarkers to guide patient selection remains an unmet clinical need. Methods: In this retrospective cohort study, 92 patients with moderate-to-severe RAR undergoing endoscopic PNN were stratified by 1-year outcome (effective: ≥50% improvement in Total Nasal Symptom Score TNSS). Preoperative serum levels of neuropeptides (Substance P, SP; Vasoactive Intestinal Peptide, VIP) were measured. Postoperative histopathological tissue eosinophil (TEos) counts (cells/HPF) from resected nasal mucosa were analyzed. Patients were categorized into Low-TEos (<10/HPF) and High-TEos (≥10/HPF) groups. Results: The overall effective rate was 88.0%. The effective group exhibited significantly higher preoperative SP (56.4±12.1 vs. 38.2±9.5 pg/mL, P<0.001) and lower TEos counts (6.5±3.2 vs. 18.4±6.7 cells/HPF, P<0.001). Low TEos count strongly correlated with greater TNSS improvement (r=-0.62, P<0.001). Multivariate analysis identified High-TEos as an independent risk factor for poor outcome (OR=4.25, 95% CI: 1.56–11.58, P=0.005). ROC analysis confirmed TEos as a robust prognostic predictor (AUC=0.845, cutoff 11.5 cells/HPF). Conclusion: High tissue eosinophilia defines an immune-endotypic subset of RAR with attenuated response to PNN, whereas a neurogenic-dominant profile (high SP, low TEos) predicts excellent surgical prognosis. TEos count serves as a clinically actionable histopathological prognostic biomarker, facilitating personalized surgical management through immune-endotype stratification.
Su et al. (2026) studied this question.