Preparation of nose for nasal endoscopy: cotton pledget packing versus topical spray. A prospective randomized blinded study

A prospective-randomized placebo-controlled trial comparing the effects of nebulized dexmedetomidine v/s dexmedetomidine-lignocaine mixture on intraoperative hemodynamics and surgical field quality in patients undergoing endoscopic transnasal transsphenoidal pituitary tumor surgery

Background

During transnasal transsphenoidal pituitary surgery (TNTSS), the primary objective is to maintain stable hemodynamics while ensuring ideal surgical conditions. This study aimed to investigate the effect of nebulized dexmedetomidine on hemodynamic parameters and the quality of the surgical field during TNTSS.

Methods

Seventy-five patients scheduled for TNTSS were randomized into three groups of 25 each and received preoperative nebulization with 5 mL of nebulizing fluid consisting of 1.5 μg/kg of dexmedetomidine with saline in dexmedetomidine (D) group; 1.5 μg/kg of dexmedetomidine with 2% lignocaine in dexmedetomidine-lignocaine (DL) group and normal saline in the control (S) group. Heart rate (HR), mean blood pressure, Formmers score, anesthetic requirement, and emergence were evaluated for each group.

Results

Group S had significantly higher HR and mean arterial pressure than the other two groups across various time points during surgery (P < 0.01). The total requirements for fentanyl, propofol, sevoflurane, and labetalol and the incidence of delayed emergence were significantly higher in the S group compared to the other two groups (P < 0.01). The D and DL groups exhibited significantly better surgical field conditions than the S group. In all the parameters assessed, patients in the D group outperformed those in the DL group.

Conclusion

The administration of nebulized dexmedetomidine, both alone and in combination with lignocaine, resulted in stable hemodynamics, favorable operative conditions, reduced anesthetic requirement, and facilitated prompt emergence during TNTSS. Nebulized dexmedetomidine proved superior to its combination with lignocaine across all evaluated parameters.

A Prospective, Randomized, Double-Blind Study on the Efficacy of Different Modes of Topical Application of Nasal Anesthetics in the Diagnostic Nasal Endoscopy Procedure

Introduction

In the current otorhinolaryngology practice, technology has always been an essential part. Therefore, diagnostic nasal endoscopy (DNE) has become a vital examination in today’s practice. In order to visualize the nasal cavity in a systematic manner without any discomfort to both patient and doctor, the nose should be well anesthetized and decongested.

Objective

The study is to compare and evaluate the efficacy of 4% lignocaine-oxymetazoline cotton pledget packing versus topical sprays in the preparation of nasal cavities for DNE.

Methodology

The prospective, randomized, double-blind study was conducted among 246 patients and was divided into two groups. In the first group, the nose was packed with cotton pledgets containing 4% lignocaine-oxymetazoline and another group with 4% lignocaine-oxymetazoline spray. Following DNE, patients and surgeons were questioned on a pre-formed questionnaire to evaluate their experience during the procedure.

Results

It was observed that the time taken for the pre-endoscopic preparation of the packing group was more than the spray group. A total of 91.9% of the spray group had pain during the pre-endoscopic preparation and more burning and tingling sensation than in the nasal pack (75.6%). A total of 69.9% of the patients among the spray group participants compared to 32.5% of the packing group patients experienced more throat discomfort. In addition, 12% of the packing group had mucosal bleeding during the preparation. A total of 32.5% of the spray group experienced severe pain when compared to 12.2% of the packing group during the endoscopic procedure. Most of the participants from both groups had difficulty visualizing the superior turbinate and sphenoethmoidal recess during the procedure. There was a significant difference seen between both the groups with respect to pain during the pre-endoscopic procedure (p=0.0005), burning/tingling sensation (p<0.0001), throat pain (<0.0001), mucosal bleed (p=0.0003), pain during the procedure (p=0.0001), and discomfort after the procedure (p<0.0001).

Conclusion

Both methods of nasal preparation have merits and demerits in terms of discomfort, pain, and visualization of structures. Still, the packing of the nasal cavity with cotton pledgets is better when compared to spraying with 4% lignocaine-oxymetazoline. However, 4% lignocaine-oxymetazoline spray can be used during an emergency situation and with sensitive patients.

Topical Vasoconstrictors in Cosmetic Rhinoplasty: Comparative Evaluation of Cocaine Versus Epinephrine Solutions

BACKGROUND

The use of topical vasoconstrictors is a common practice in nasal surgery. These agents reduce bleeding and enable a good surgical field. Topical cocaine and epinephrine, which are frequently used in cosmetic rhinoplasty, are considered safe and effective, but secondary effects have been described. The aim of the present study was to evaluate and compare the benefits and risks of epinephrine and cocaine employed as topical vasoconstrictive agents in cosmetic rhinoplasty.

METHODS

This prospective non-randomised study included 65 consecutive female patients undergoing primary closed rhinoplasty. Patients were treated with topical aqueous solutions of 4 % cocaine (n = 33) or 1:1000 epinephrine (n = 32). Benefits and risks of drug use were compared between groups. Vasoconstriction was assessed by quantitative and qualitative evaluation of bleeding during surgery. Systemic effects were studied in terms of cardiovascular changes during the procedure. The Mann-Whitney test and mixed-effects models were used to compare continuous variables and to assess the effects of vasoconstrictor treatment, respectively.

RESULTS

Cocaine exerted a stronger and more predictable vasoconstrictive effect than epinephrine. This difference was linked to better field quality, but did not relate to shorter surgery times. Increased heart rate was detected with both agents and was significantly higher with cocaine (p < 0.05). Blood pressure did not significantly differ between groups.

CONCLUSIONS

Both cocaine and epinephrine, at the concentrations used in this study, are suitable as topical vasoconstrictive agents in aesthetic rhinoplasty.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Premedication Methods in Nasal Endoscopy: A Prospective, Randomized, Double-Blind Study

Objectives

To identify the optimal pharmacological method of preparing patients for nasal endoscopy.

Methods

Twenty healthy volunteers were enrolled in this prospective, randomized, double-blind study. Four types of medications were applied in their nostrils with binary combinations of spray bottles on four different days in a random order: placebo (normal saline [NS]+NS), decongestant (NS+oxymetazoline), anesthetic (NS+lidocaine), and decongestant plus anesthetic (oxymetazoline+lidocaine). Rigid nasal endoscopy was performed 10 minutes after spray application. The volunteers evaluated the discomfort caused by each spray application, and nasal pain scores due to the passage of the endoscope. The physicians quantified nasal decongestion using a visual analogue scale. Endoscopy duration as well as pulse and mean blood pressure (MBP) before spray application, 10 minutes after the application, and immediately after endoscopic examination were also recorded.

Results

The discomfort caused by lidocaine was significantly higher than that caused by the other sprays (P<0.001). The lowest pain score related to endoscopy was obtained for oxymetazoline+lidocaine (P<0.001). Nasal decongestion was best achieved with NS+oxymetazoline (P<0.001). Endoscopy duration was the shortest for oxymetazoline+ lidocaine (P<0.05). Statistically significant MBP changes were only seen with the application of NS+oxymetazoline (P<0.05). However, neither MBP nor pulse rate change was significant clinically.

Conclusion

Application of decongestant and anesthetic sprays together seems to be the best method of pharmacological preparation of patients for nasal endoscopy.

Assessing the safety and efficacy of drugs used in preparing the nose for diagnostic and therapeutic procedures: a systematic review

BACKGROUND

Local anaesthetics and vasoconstrictors are essential for pain control and to aid intra-operative haemostasis in nasal procedures. They also improve access, and reduce discomfort when performing nasal endoscopy. There are no clear guidelines on preparing the nose despite evermore diagnostic and therapeutic procedures utilising the nose as a point of access.

OBJECTIVE OF REVIEW

This review aims to identify nasal preparations used in diagnostic and therapeutic nasal procedures and to examine their safety and efficacy.

TYPE OF REVIEW

Systematic review.

SEARCH STRATEGY

A search was carried out using PubMed, MEDLINE, Ovid EMBASE, the Cochrane library and references from the included articles.

EVALUATION METHOD

The inclusion criteria included: full-text English language articles with regard to nasal preparation for surgery. Case reports, systematic reviews, meta-analysis, double-blind placebo controlled randomised trials (RCTs) and case series were included.

RESULTS

A total of 53 articles were retrieved: 13 articles on nasal preparation for operative procedures, six on functional endoscopic sinus surgery and 22 on nasendoscopy as well as six case reports. Cocaine was the most widely used topical preparation for operative procedures but was associated with more side-effects; thus, topical tetracaine and levobupivacaine infiltration are alternatives with equivalent efficacy but reduced adverse effects. All articles reviewed for functional endoscopic sinus surgery used a mixture containing lidocaine, adrenaline or both. Flexible nasendoscopy causes minimal patient discomfort and preparation is only recommended in selected patients, in contrast to rigid nasendoscopy which requires preparation.

CONCLUSION

For operative procedures, such as septorhinoplasty, a single agent tetracaine or levobupivicaine provides an improved surgical field. In functional endoscopic sinus surgery, lidocaine-adrenaline preparations have resulted in significantly better surgical and patient outcomes. There is little evidence to support the routine use of pre-procedural nasal preparation for flexible nasendoscopy. Those undergoing rigid endoscopy conversely always require the use of a vasoconstrictor and local anaesthetic. Pre-procedure assessment of patients is recommended, with agents being reserved for those with low pain thresholds, high anxiety and small nasal apertures presenting resistance to the insertion of the endoscope.

Topical anesthetic preparations for rigid and flexible endoscopy: a meta-analysis

Transnasal endoscopy can cause pain or discomfort for the patient. Topical anesthetic has been used in an attempt to reduce this. However, there is no consensus on whether topical anesthetic is effective in optimizing patient experience during the procedure. The goal of this study was to perform a systematic review with meta-analysis of the efficacy of topical anesthetic on pain and comfort outcomes during endoscopy. Two authors independently searched the databases from inception to September 2013. Studies comparing topical anesthetic with placebo where the outcomes of interest were pain, comfort, or side effect outcomes were included. Sufficient data for meta-analysis were retrieved for ten trials with a total of 837 patients. The evidence suggests that local anesthetic alone or in combination with a vasoconstrictor is beneficial to patients' pain [standardized mean difference (SMD) = -0.21; p = 0.045] and comfort (SMD = -0.51; p < 0.001) outcomes when performing transnasal endoscopy. However, the topical anesthetic caused unpleasant sensation with respect to an unpleasant taste (SMD = 0.77; p < 0.001). In addition, there was no significant difference between a topical anesthetic spray and cotton type in pain and discomfort values. Applying topical anesthetic during transnasal endoscopy could reduce pain and discomfort. The spray and cotton type methods of topical anesthetic preparation showed no significant difference in terms of pain and discomfort during the procedure. However, further trials with good research methodology should be conducted to confirm our results.