1
|
Teng TZJ, Chia AZQ, Gan KF, Tan LHP, Wang Y, Charn TC. A Comparison of Tranexamic Acid in Nasal Versus Sinus Surgeries: a Systematic Review and Meta-Analysis. Indian J Otolaryngol Head Neck Surg 2024; 76:3018-3030. [PMID: 39130301 PMCID: PMC11306473 DOI: 10.1007/s12070-024-04579-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 02/22/2024] [Indexed: 08/13/2024] Open
Abstract
Nasal surgeries (e.g.: rhinoplasties, septoplasties) and sinus surgeries (e.g.: Functional Endoscopic Sinus Surgeries) are common procedures in Otorhinolaryngology. Tranexamic acid (TXA), an antifibrinolytic drug, has been increasingly utilized to reduce hemorrhage recently. While close in proximity anatomically, the bleeding nature of sinus and nasal surgeries may differ. We present the first meta-analysis that has reviewed both nasal and sinus surgery collectively and compares the two. Pubmed, Embase, Cochrane Library and WoS were searched until April 2023. Outcomes of interest include Boezart Scoring, clotting time, postoperative complications and surgical field quality. 27 Studies were assessed, of which 25 studies were evaluated quantitatively. Of the 27 studies, 15 studies involved Sinus surgery while 12 involved Nasal surgery. The use of tranexamic acid was notably beneficial in the evaluation of blood loss, reduction of operating time, surgical field quality and surgeon satisfaction. TXA has proven to be efficacious in both nasal and sinus surgeries to varying degrees. TXA has more effects in sinus surgeries compared to nasal surgeries in objective markers such as reducing blood loss and operating time, but the converse occurs for subjective markers such as surgeon satisfaction scores. Supplementary Information The online version contains supplementary material available at 10.1007/s12070-024-04579-x.
Collapse
Affiliation(s)
- Thomas Zheng Jie Teng
- Ministry of Health Holdings, Singapore, Singapore
- Department of Otorhinolaryngology - Head and Neck surgery, Sengkang General Hospital, Singhealth, Singapore
| | | | - Keith Fei Gan
- Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore, Singapore
| | - Lydia Hui Peng Tan
- Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore, Singapore
| | - Yuxing Wang
- Ministry of Health Holdings, Singapore, Singapore
| | - Tze Choong Charn
- Department of Otorhinolaryngology - Head and Neck surgery, Sengkang General Hospital, Singhealth, Singapore
| |
Collapse
|
2
|
Miyashita K, Tochigi K, Omura K, Aoki S, Tanaka Y. Preventive effects of skin protectants on the development of medical device-related pressure wounds in endoscopic sinonasal surgery. Auris Nasus Larynx 2023; 50:880-886. [PMID: 36906471 DOI: 10.1016/j.anl.2023.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 02/15/2023] [Accepted: 02/24/2023] [Indexed: 03/13/2023]
Abstract
OBJECTIVES Medical device-related pressure ulcer (MDRPU) is a skin or subcutaneous tissue injury caused by medical devices. Skin protectants have been used to prevent MDRPU in other fields. In endoscopic sinonasal surgery (ESNS), rigid endoscopes and forceps can cause MDRPU; however, detailed investigations have not been conducted. This study aimed to investigate the frequency of MDRPU in ESNS and the preventive effects of skin protectants METHODS: Thirty-nine patients who received ESNS and consented to study participation were randomly assigned to the "protective agent" (n = 18) or "control" (n = 21) group. MDRPU presence around the nostril was evaluated for up to 7 days post-surgically based on physical findings and subjective symptoms. The occurrence ratio and severity of MDRPU were statistically compared between the groups to evaluate the efficacy of skin protective agents. RESULTS Stage 1 MDRPU, according to the National Pressure Ulcer Advisory Panel classification, was seen in 20.5% (8/39) of the patients, and no patient had more high-grade ulceration. On postoperative days 2 and 3, skin erythema was predominantly observed on the nasal floor, with a comparatively lower incidence in the protective agent group. Significant pain reduction was observed in the nostril's floor on postoperative days 2 and 3 in the protective agent group. CONCLUSIONS MDRPU occurred with a relatively high frequency around the nostrils after ESNS. Protective agent use in the external nostrils was effective especially in reducing post-operative pain on the nasal floor, where tissue damage can easily occur due to device-related friction.
Collapse
Affiliation(s)
- Keisuke Miyashita
- Department of Otorhinolaryngology/Head and Neck Surgery, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Kousuke Tochigi
- Department of Otorhinolaryngology/Head and Neck Surgery, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Kazuhiro Omura
- Department of Otorhinolaryngology/Head and Neck Surgery, Dokkyo Medical University Saitama Medical Center, Saitama, Japan; Department of Otorhinolaryngology/Head and Neck Surgery, The Jikei University School of Medicine, Tokyo, Japan.
| | - Satoshi Aoki
- Department of Otorhinolaryngology/Head and Neck Surgery, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Yasuhiro Tanaka
- Department of Otorhinolaryngology/Head and Neck Surgery, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| |
Collapse
|
3
|
Zhang B, Zhuang L, Cai C, Qi Y. Effect of Nasal Submucosal Injection of Low-concentration Epinephrine on Visual Field Visualization in Endoscopic Sinus Surgery: A Systematic Review and Meta-analysis. EAR, NOSE & THROAT JOURNAL 2023:1455613231192824. [PMID: 37574871 DOI: 10.1177/01455613231192824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2023] Open
Abstract
Objective: To determine whether nasal submucosal injection of low-concentration epinephrine improved the surgical field visualization and physician satisfaction compared to placebo or without intervention. Methods: A literature search of PubMed, Scopus, Web of Science, Cochrane library, China National Knowledge Infrastructure, and Wanfang Database was conducted from inception to January 10, 2023. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Meta-analyses were performed using Review Manager (RevMan version 5.3; the Cochrane Collaboration). Quality was assessed by 2 reviewers using the Cochrane Risk of Bias Tool. And we used funnel plots to visually assess the risk of publication bias. Results: We included a total of 11 studies with 492 patients, all of which were randomized controlled trials. Among the studies, 4 had a low risk of bias, 4 had a moderate risk of bias, and 3 had a high risk of bias. Five studies reported visual bleeding grade in the surgical field (P = 0.07) and total blood loss (P = 0.16), 8 studies reported preoperative baseline heart rate (P = 0.58) and baseline mean arterial pressure (MAP) (P = 0.78), and 9 studies reported intraoperative heart rate (P = 0.27) and MAP (P = 0.56), which showed no significant differences in these parameters between the 2 groups. None of these outcomes were statistically significant between the epinephrine group and the control group. Conclusion: There is insufficient evidence to support the nasal submucosal application of low-concentration epinephrine to improve surgical field dryness and reduce total surgical bleeding.
Collapse
Affiliation(s)
- Bi Zhang
- Department of Anesthesia, Ningbo Medical Center Li Huili Hospital, Ningbo, Zhejiang, China
| | - Liye Zhuang
- Department of Anesthesia, Ningbo Medical Center Li Huili Hospital, Ningbo, Zhejiang, China
| | - Chang Cai
- Department of Anesthesia, Ningbo Medical Center Li Huili Hospital, Ningbo, Zhejiang, China
| | - Yong Qi
- Department of Anesthesia, Ningbo Medical Center Li Huili Hospital, Ningbo, Zhejiang, China
| |
Collapse
|
4
|
Alrajhi AA, Alghamdi AS, Baali MH, Altowairqi AF, Khan MF, Alharthi AS, Albazee E, Abu-Zaid A. Efficacy of prophylactic pre-operative desmopressin administration during functional endoscopic sinus surgery for chronic rhinosinusitis: A systematic review and meta-analysis of randomised placebo-controlled trials. Clin Otolaryngol 2023; 48:139-150. [PMID: 36536598 DOI: 10.1111/coa.14020] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 12/03/2022] [Accepted: 12/10/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVES To examine the efficacy of prophylactic desmopressin versus placebo among patients undergoing functional endoscopic sinus surgery (FESS). DESIGN Systematic review and meta-analysis of randomised controlled trials (RCTs). SETTING The Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Embase, Scopus, and Web of Science databases were screened from inception until 18 March 2022. PARTICIPANTS Patients undergoing FESS. MAIN OUTCOME MEASURES Primary efficacy endpoints comprised intraoperative blood loss, visual clarity, and operation time. Secondary endpoints comprised side effects. The efficacy endpoints were summarised as risk ratio (RR) or mean difference (MD) with 95% confidence interval (CI). RESULTS Five RCTs comprising 380 patients (desmopressin = 191 patients and placebo = 189 patients) were included. Collectively, the included RCTs had an overall low risk of bias. The pooled results showed that the mean intraoperative blood loss (n = 5 RCTs, MD = -37.97 ml, 95% CI [-56.97, -18.96], p < .001), 5-point Boezaart scores (n = 2 RCTs, MD = -.97, 95% CI [-1.21, -.74], p < .001), and 10-point Boezaart scores (n = 2 RCTs, MD = -3.00, 95% CI [-3.61, -2.40], p < .001) were significantly reduced in favour of the desmopressin group compared with the placebo group. Operation time did not significantly differ between both groups (n = 5 RCTs, MD = -3.73 min, 95% CI [-14.65, 7.18], p = .50). No patient in both groups developed symptomatic hyponatremia (n = 3 RCTs, 194 patients) or thromboembolic events (n = 2 RCTs, 150 patients). CONCLUSIONS Among patients undergoing FESS, prophylactic administration of desmopressin does not correlate with significant clinical benefits. Data on safety is limited. Future research may explore the synergistic antihaemorrhagic efficacy and safety of tranexamic acid (TXA) plus desmopressin versus TXA alone among patients undergoing FESS.
Collapse
Affiliation(s)
- Abdullah Abdulaziz Alrajhi
- Department of Otolaryngology and Head and Neck Surgery, Al-Noor Specialist Hospital, Makkah, Saudi Arabia
| | - Abdullah Shakhs Alghamdi
- Department of Otolaryngology and Head and Neck Surgery, Al-Hada Armed Forces Hospital, Taif, Saudi Arabia
| | - Mohammed Hassan Baali
- Department of Otolaryngology and Head and Neck Surgery, King Faisal Medical Complex, Taif, Saudi Arabia
| | - Abdulaziz Fahad Altowairqi
- Department of Otolaryngology and Head and Neck Surgery, King Abdulaziz Specialist Hospital, Taif, Saudi Arabia
| | - Meshal Fahad Khan
- Department of Otolaryngology and Head and Neck Surgery, Al-Noor Specialist Hospital, Makkah, Saudi Arabia
| | - Ahmad Saad Alharthi
- Department of Otolaryngology and Head and Neck Surgery, Al-Hada Armed Forces Hospital, Taif, Saudi Arabia
| | - Ebraheem Albazee
- Kuwait Institute for Medical Specializations, Kuwait City, Kuwait
| | - Ahmed Abu-Zaid
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia.,College of Graduate Health Sciences, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| |
Collapse
|
5
|
Lourijsen E, Avdeeva K, Gan KL, Pundir V, Fokkens W. Tranexamic acid for the reduction of bleeding during functional endoscopic sinus surgery. Cochrane Database Syst Rev 2023; 2:CD012843. [PMID: 36808096 PMCID: PMC9943060 DOI: 10.1002/14651858.cd012843.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
BACKGROUND Chronic rhinosinusitis, with or without nasal polyps, can have a major impact on a person's quality of life. Treatment is usually conservative and may include nasal saline, intranasal corticosteroids, antibiotics or systemic corticosteroids. If these treatments fail endoscopic sinus surgery can be considered. During surgery, visibility of the surgical field is important for the identification of important anatomic landmarks and structures that contribute to safety. Impaired visualisation can lead to complications during surgery, inability to complete the operation or a longer duration of surgery. Different methods are used to decrease intraoperative bleeding, including induced hypotension, topical or systemic vasoconstrictors or total intravenous anaesthesia. Another option is tranexamic acid, an antifibrinolytic agent, which can be administered topically or intravenously. OBJECTIVES To assess the effects of peri-operative tranexamic acid versus no therapy or placebo on operative parameters in patients with chronic rhinosinusitis (with or without nasal polyps) who are undergoing functional endoscopic sinus surgery (FESS). SEARCH METHODS The Cochrane ENT Information Specialist searched the Cochrane ENT Trials Register; Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid Embase; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 10 February 2022. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing intravenous, oral or topical tranexamic acid with no therapy or placebo in the treatment of patients (adults and children) with chronic rhinosinusitis, with or without nasal polyps, undergoing FESS. DATA COLLECTION AND ANALYSIS We used the standard methodological procedures expected by Cochrane. Primary outcome measures were surgical field bleeding score (e.g. Wormald or Boezaart grading system), intraoperative blood loss and significant adverse effects (seizures or thromboembolism within 12 weeks of surgery). Secondary outcomes were duration of surgery, incomplete surgery, surgical complications and postoperative bleeding (placing of packing or revision surgery) in the first two weeks after surgery. We performed subgroup analyses for methods of administration, different dosages, different forms of anaesthesia, use of thromboembolic prophylaxis and children versus adults. We evaluated each included study for risk of bias and used GRADE to assess the certainty of the evidence. MAIN RESULTS We included 14 studies in the review, with a total of 942 participants. Sample sizes in the included studies ranged from 10 to 170. All but two studies included adult patients (≥ 18 years). Two studies included children. Most studies had more male patients (range 46.6% to 80%). All studies were placebo-controlled and four studies had three treatment arms. Three studies investigated topical tranexamic acid; the other studies reported the use of intravenous tranexamic acid. For our primary outcome, surgical field bleeding score measured with the Boezaart or Wormald grading score, we pooled data from 13 studies. The pooled result demonstrated that tranexamic acid probably reduces the surgical field bleeding score, with a standardised mean difference (SMD) of -0.87 (95% confidence interval (CI) -1.23 to -0.51; 13 studies, 772 participants; moderate-certainty evidence). A SMD below -0.70 represents a large effect (in either direction). Tranexamic acid may result in a slight reduction in blood loss during surgery compared to placebo with a mean difference (MD) of -70.32 mL (95% CI -92.28 to -48.35 mL; 12 studies, 802 participants; low-certainty evidence). Tranexamic acid probably has little to no effect on the development of significant adverse events (seizures or thromboembolism) within 24 hours of surgery, with no events in either group and a risk difference (RD) of 0.00 (95% CI -0.02 to 0.02; 8 studies, 664 participants; moderate-certainty evidence). However, there were no studies reporting significant adverse event data with a longer duration of follow-up. Tranexamic acid probably results in little difference in the duration of surgery with a MD of -13.04 minutes (95% CI -19.27 to -6.81; 10 studies, 666 participants; moderate-certainty evidence). Tranexamic acid probably results in little to no difference in the incidence of incomplete surgery, with no events in either group and a RD of 0.00 (95% CI -0.09 to 0.09; 2 studies, 58 participants; moderate-certainty evidence) and likely results in little to no difference in surgical complications, again with no events in either group and a RD of 0.00 (95% CI -0.09 to 0.09; 2 studies, 58 participants; moderate-certainty evidence), although these numbers are too small to draw robust conclusions. Tranexamic acid may result in little to no difference in the likelihood of postoperative bleeding (placement of packing or revision surgery within three days of surgery) (RD -0.01, 95% CI -0.04 to 0.02; 6 studies, 404 participants; low-certainty evidence). There were no studies with longer follow-up. AUTHORS' CONCLUSIONS There is moderate-certainty evidence to support the beneficial value of topical or intravenous tranexamic acid during endoscopic sinus surgery with respect to surgical field bleeding score. Low- to moderate-certainty evidence suggests a slight decrease in total blood loss during surgery and duration of surgery. Whilst there is moderate-certainty evidence that tranexamic acid does not lead to more immediate significant adverse events compared to placebo, there is no evidence regarding the risk of serious adverse events more than 24 hours after surgery. There is low-certainty evidence that tranexamic acid may not change postoperative bleeding. There is not enough evidence available to draw robust conclusions about incomplete surgery or surgical complications.
Collapse
Affiliation(s)
- Evelijn Lourijsen
- Department of Otorhinolaryngology, Amsterdam UMC location AMC, Amsterdam, Netherlands
| | - Klementina Avdeeva
- Department of Otorhinolaryngology, Amsterdam UMC location AMC, Amsterdam, Netherlands
| | - Kit Liang Gan
- Department of Otorhinolaryngology, Mahkota Medical Centre, Melaka, Malaysia
| | - Vishal Pundir
- Department of Otorhinolaryngology, Maidstone and Tunbridge Wells NHS Trust, Tunbridge Wells, UK
| | - Wytske Fokkens
- Department of Otorhinolaryngology, Amsterdam UMC location AMC, Amsterdam, Netherlands
| |
Collapse
|
6
|
Vuncannon JR, Wise SK. Hemostasis in endoscopic sinus and skull base surgery. Curr Opin Otolaryngol Head Neck Surg 2023; 31:33-38. [PMID: 36730664 DOI: 10.1097/moo.0000000000000855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE OF REVIEW Bleeding during endoscopic endonasal procedures can quickly obscure critical anatomic landmarks. This increases both the difficulty of the surgical procedure and the risk of complications faced by the patient. As the indications for surgical management of sinonasal pathology grow, it is important to review techniques to minimize bleeding and facilitate safe surgery. RECENT FINDINGS Evidence continues to accumulate for best practices in the surgical management of sinonasal disease. Recently, international guidelines have attempted to summarize this body of evidence, lending further support to several interventions which have been advocated as methods to decrease bleeding during endoscopic endonasal surgery. Additional studies have specifically investigated the safety of certain commonly employed techniques. The utility of preoperative corticosteroid therapy and the use of total intravenous anesthetic techniques in increasingly validated. Further evidence supports the safety of reverse Trendelenburg positioning for surgical management of inflammatory disease. SUMMARY Recent wide scale systematic review of the literature regarding perioperative and intraoperative management of hemostasis has reinforced the utility of certain interventions, while others remain ambiguous.
Collapse
Affiliation(s)
- Jackson R Vuncannon
- Emory University School of Medicine, Department of Otolaryngology - Head and Neck Surgery, Atlanta, GA
| | | |
Collapse
|
7
|
Hofmann A, Aapro M, Fedorova TA, Zhiburt YB, Snegovoy AV, Kaganov OI, Ognerubov NA, Lyadov VK, Moiseenko VM, Trofimova OP, Ashrafyan LA, Khasanov RS, Poddubnaya IV. Patient blood management in oncology in the Russian Federation: Resolution to improve oncology care. J Cancer Policy 2022; 31:100315. [DOI: 10.1016/j.jcpo.2021.100315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 08/31/2021] [Accepted: 12/07/2021] [Indexed: 11/16/2022]
|
8
|
The effects of 5-degree, 10-degree and 20-degree reverse Trendelenburg positions on intraoperative bleeding and postoperative Edemea and ecchymosis around the eye in open rhinoplasty. Am J Otolaryngol 2022; 43:103311. [PMID: 34894451 DOI: 10.1016/j.amjoto.2021.103311] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 11/28/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE In this study, we investigated the effect of reverse Trendelenburg position (RTP), with five, ten, and twenty degrees, on intraoperative bleeding and postoperative edema and ecchymosis around the eye in open rhinoplasty operations. MATERIALS AND METHODS Ninety patients undergoing open rhinoplasty were divided into three groups, 5° angle RTP (Group 5; n = 30), 10° angle RTP (Group 10; n = 30), and 20° angle RTP (Group 20; n = 30). After 3 min of preoxygenation, anesthesia was induced with 3 mg.kg-1 propofol, 1 μg.kg-1 fentanyl, and 0.6 mg/kg rocuronium for muscle relaxation. Maintenance of anesthesia was provided with a minimum alveolar concentration of 1-1.5 with sevoflurane, 1:1 O2/N2O. Hemodynamic variables, intraoperational bleeding, postoperative 1st, 3rd and 7th days ecchymosis and edema around the eyes of the patients were compared between the groups. RESULTS Edema changes on postoperative 1st, 3rd and 7th days and ecchymosis changes around the eyes on postoperative 1st and 3rd days in Group 20 were found significantly lower than Group 5 (p < 0.017). Besides, the change of ecchymosis on the postoperative 1st day was found significantly lower in Group 20 compared to Group 10 (p < 0.017). The amount of intraoperative bleeding and surgical field evaluation score were found to be significantly lower in Group 10 and Group 20 compared to Group 5 (p < 0.017). CONCLUSION We concluded that in open rhinoplasty surgeries, 20° degree RTP reduces intraoperative blood loss and provides a more bloodless surgical field, as well as reducing edema and ecchymoses around the eyes in the postoperative period.
Collapse
|
9
|
Hot Saline Irrigation for Haemostasis in Functional Endoscopic Sinus Surgery: A Systematic Review and Meta-analysis. The Journal of Laryngology & Otology 2021; 136:676-682. [PMID: 34819186 DOI: 10.1017/s0022215121003698] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|
10
|
Stasiowski MJ, Szumera I, Wardas P, Król S, Żak J, Missir A, Pluta A, Niewiadomska E, Krawczyk L, Jałowiecki P, Grabarek BO. Adequacy of Anesthesia and Pupillometry for Endoscopic Sinus Surgery. J Clin Med 2021; 10:jcm10204683. [PMID: 34682812 PMCID: PMC8537175 DOI: 10.3390/jcm10204683] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 10/07/2021] [Accepted: 10/11/2021] [Indexed: 01/14/2023] Open
Abstract
Inadequate intraoperative analgesia causes the deterioration of the condition of the surgical field (CSF) as a result of hemodynamic instability. Analgesia monitors are used to guide remifentanil) infusion to optimize intraoperative analgesia. The main aim of the current randomized controlled trial was to investigate the potential advantages of intraoperative analgesia monitoring using surgical Pleth index (SPI)- or pupillometry (PRD)-guided remifentanil administration for managing the volume of total intraoperative blood loss (TEIBL), CSF, and length of operation (LOP) in comparison with the standard practice in patients undergoing endoscopic sinus surgery (ESS). The 89 patients in our study were grouped as follows: 30 patients were assigned to the general analgesia (GA) group, 31 patients were assigned to the SPI group, and 28 patients were assigned to the PRD group. The speed of remifentanil infusion was accelerated by 50% when SPI, PRD, or BSS were increased by >15 points, >5%, or >2, respectively, in adjacent groups until their normalization. The SPI group showed significantly lower TEIBL in comparison to the GA group (165.2 ± 100.2 vs. 283.3 ± 193.5 mL; p < 0.05) and a higher mean arterial pressure (MAP; 73.9 ± 8 vs. 69.2 ± 6.8 mmHg; p < 0.05). In the PRD group, a shorter LOP compared with the GA group was observed (63.1 ± 26.7 min vs. 82.6 ± 33.1 min; p < 0.05). It was noted that the PRD group had a lower total remifentanil consumption than the SPI group (1.3 ± 1.4 vs. 1.8 ± 0.9 mg; p < 0.05). In ASA I-III patients undergoing ESS, intraoperative monitoring based on state entropy and SPI values can optimize the CSF and reduce TEIBL, whereas monitoring based on state entropy and PRD measurements can optimize the cost effectiveness of anesthetic drugs and the use of the operation room.
Collapse
Affiliation(s)
- Michał Jan Stasiowski
- Chair and Department of Emergency Medicine, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, 40-055 Katowice, Poland; (I.S.); (S.K.); (A.M.); (A.P.); (L.K.); (P.J.)
- Department of Anaesthesiology and Intensive Care, 5th Regional Hospital, 41-200 Sosnowiec, Poland;
- Correspondence:
| | - Izabela Szumera
- Chair and Department of Emergency Medicine, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, 40-055 Katowice, Poland; (I.S.); (S.K.); (A.M.); (A.P.); (L.K.); (P.J.)
- Department of Anaesthesiology and Intensive Care, 5th Regional Hospital, 41-200 Sosnowiec, Poland;
| | - Piotr Wardas
- Chair and Clinical Department of Laryngology, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-055 Katowice, Poland;
| | - Seweryn Król
- Chair and Department of Emergency Medicine, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, 40-055 Katowice, Poland; (I.S.); (S.K.); (A.M.); (A.P.); (L.K.); (P.J.)
- Department of General, Colorectal and Polytrauma Surgery, Faculty of Health Sciences in Katowice, Medical University of Silesia, 40-555 Katowice, Poland
| | - Jakub Żak
- Department of Anaesthesiology and Intensive Care, 5th Regional Hospital, 41-200 Sosnowiec, Poland;
| | - Anna Missir
- Chair and Department of Emergency Medicine, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, 40-055 Katowice, Poland; (I.S.); (S.K.); (A.M.); (A.P.); (L.K.); (P.J.)
- Department of Neurosurgery, Regional Hospital in Sosnowiec, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-055 Katowice, Poland
| | - Aleksandra Pluta
- Chair and Department of Emergency Medicine, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, 40-055 Katowice, Poland; (I.S.); (S.K.); (A.M.); (A.P.); (L.K.); (P.J.)
- Department of Anaesthesiology and Intensive Care, 5th Regional Hospital, 41-200 Sosnowiec, Poland;
| | - Ewa Niewiadomska
- Department of Epidemiology and Biostatistics, Faculty of Public Health in Bytom, Medical University of Silesia, 40-555 Katowice, Poland;
| | - Lech Krawczyk
- Chair and Department of Emergency Medicine, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, 40-055 Katowice, Poland; (I.S.); (S.K.); (A.M.); (A.P.); (L.K.); (P.J.)
- Department of Anaesthesiology and Intensive Care, 5th Regional Hospital, 41-200 Sosnowiec, Poland;
| | - Przemysław Jałowiecki
- Chair and Department of Emergency Medicine, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, 40-055 Katowice, Poland; (I.S.); (S.K.); (A.M.); (A.P.); (L.K.); (P.J.)
- Department of Anaesthesiology and Intensive Care, 5th Regional Hospital, 41-200 Sosnowiec, Poland;
| | - Beniamin Oskar Grabarek
- Department of Histology, Cytophysiology and Embryology, Faculty of Medicine, University of Technology in Katowice, 41-800 Zabrze, Poland;
| |
Collapse
|
11
|
The effect of intranasal irrigation with epinephrine solution on intraoperative visualization and bleeding during FESS. Eur Arch Otorhinolaryngol 2021; 279:1911-1917. [PMID: 34175968 DOI: 10.1007/s00405-021-06952-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 06/21/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Bleeding during Functional endoscopic sinus surgery (FESS) can have adverse effect on surgical outcomes. This study evaluates if there is any benefit of adding epinephrine to the saline nasal irrigation in patients undergoing elective FESS for chronic rhinosinusitis. METHODS A prospective, randomized, double-blinded study was performed. Fifty ASA I or II patients undergoing FESS were randomized to have irrigation either with normal saline or (1:100,000) epinephrine in normal saline during surgery. Outcomes measure included the Boezaart grading scale to assess the intraoperative surgical field, surgeon's satisfaction with field visualization and bleeding which was evaluated in a 10 cm visual analog scale, estimated blood loss as well as hemodynamic parameters changes. RESULTS There was no statistically significant difference in the studied variables between both groups. However in patients with higher than 12 Lund-Mackay score the volume of blood loss was significantly less in the epinephrine group. All surgical procedures were completed and there were no operative complications or any reported perioperative cardiovascular events. CONCLUSIONS Intraoperative irrigation with saline-epinephrine solution at a concentration of (1:100,000) is safe and does not change heart rate or blood pressure but is unlikely to improve the setting of intraoperative surgical field except for decreasing the volume of blood loss in patients with high Lund-Mackay score.
Collapse
|
12
|
Orlandi RR, Kingdom TT, Smith TL, Bleier B, DeConde A, Luong AU, Poetker DM, Soler Z, Welch KC, Wise SK, Adappa N, Alt JA, Anselmo-Lima WT, Bachert C, Baroody FM, Batra PS, Bernal-Sprekelsen M, Beswick D, Bhattacharyya N, Chandra RK, Chang EH, Chiu A, Chowdhury N, Citardi MJ, Cohen NA, Conley DB, DelGaudio J, Desrosiers M, Douglas R, Eloy JA, Fokkens WJ, Gray ST, Gudis DA, Hamilos DL, Han JK, Harvey R, Hellings P, Holbrook EH, Hopkins C, Hwang P, Javer AR, Jiang RS, Kennedy D, Kern R, Laidlaw T, Lal D, Lane A, Lee HM, Lee JT, Levy JM, Lin SY, Lund V, McMains KC, Metson R, Mullol J, Naclerio R, Oakley G, Otori N, Palmer JN, Parikh SR, Passali D, Patel Z, Peters A, Philpott C, Psaltis AJ, Ramakrishnan VR, Ramanathan M, Roh HJ, Rudmik L, Sacks R, Schlosser RJ, Sedaghat AR, Senior BA, Sindwani R, Smith K, Snidvongs K, Stewart M, Suh JD, Tan BK, Turner JH, van Drunen CM, Voegels R, Wang DY, Woodworth BA, Wormald PJ, Wright ED, Yan C, Zhang L, Zhou B. International consensus statement on allergy and rhinology: rhinosinusitis 2021. Int Forum Allergy Rhinol 2021; 11:213-739. [PMID: 33236525 DOI: 10.1002/alr.22741] [Citation(s) in RCA: 390] [Impact Index Per Article: 130.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 11/09/2020] [Indexed: 02/06/2023]
Abstract
I. EXECUTIVE SUMMARY BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document. METHODS ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary. RESULTS ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided. CONCLUSION This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.
Collapse
Affiliation(s)
| | | | | | | | | | - Amber U Luong
- University of Texas Medical School at Houston, Houston, TX
| | | | - Zachary Soler
- Medical University of South Carolina, Charleston, SC
| | - Kevin C Welch
- Feinberg School of Medicine, Northwestern University, Chicago, IL
| | | | | | | | | | - Claus Bachert
- Ghent University, Ghent, Belgium.,Karolinska Institute, Stockholm, Sweden.,Sun Yatsen University, Gangzhou, China
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - David A Gudis
- Columbia University Irving Medical Center, New York, NY
| | - Daniel L Hamilos
- Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | | | - Richard Harvey
- University of New South Wales and Macquarie University, Sydney, New South Wales, Australia
| | | | | | | | | | - Amin R Javer
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | | | | | | | | | | | | | | | | | - Valerie Lund
- Royal National Throat Nose and Ear Hospital, UCLH, London, UK
| | - Kevin C McMains
- Uniformed Services University of Health Sciences, San Antonio, TX
| | | | - Joaquim Mullol
- IDIBAPS Hospital Clinic, University of Barcelona, Barcelona, Spain
| | | | | | | | | | | | | | | | | | | | - Alkis J Psaltis
- University of Adelaide, Adelaide, South Australia, Australia
| | | | | | | | - Luke Rudmik
- University of Calgary, Calgary, Alberta, Canada
| | - Raymond Sacks
- University of New South Wales, Sydney, New South Wales, Australia
| | | | | | | | | | | | | | | | | | | | | | | | | | - De Yun Wang
- National University of Singapore, Singapore, Singapore
| | | | | | | | - Carol Yan
- University of California San Diego, La Jolla, CA
| | - Luo Zhang
- Capital Medical University, Beijing, China
| | - Bing Zhou
- Capital Medical University, Beijing, China
| |
Collapse
|
13
|
Khanwalkar AR, Welch KC. Updates in techniques for improved visualization in sinus surgery. Curr Opin Otolaryngol Head Neck Surg 2021; 29:9-20. [PMID: 33315617 DOI: 10.1097/moo.0000000000000693] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW Adequate visualization during endoscopic sinus surgery (ESS) is one of the most critical aspects of performing well tolerated and successful surgery. The topic of visualization encompasses a broad spectrum of preoperative and intraoperative manoeuvres the surgeon can perform that aid in the understanding of the patient's anatomy and in the delivery of efficient surgical care. RECENT FINDINGS Preoperative considerations to improve visualization include optimization of haemostasis through management of comorbidities (e.g. hypertension, coagulopathies), medication management (e.g. blood thinners) and systemic versus topical corticosteroids. New technologies allow preoperative visual mapping of surgical plans. Advances in knowledge of intraoperative anaesthesia have encouraged a move toward noninhaled anaesthetics to reduce bleeding. High definition cameras, angled endoscopes, 3D endoscopes and more recently augmented reality, image-guided surgery, and robotic surgery, represent the state of the art for high-quality visualization. Topical interventions, such as epinephrine, tranexamic acid and warm isotonic saline, can help to reduce bleeding and improve the operative field. Surgical manoeuvres, such as polyp debulking, septoplasty, carefully controlled tissue manipulation and a consistent repeatable approach remain fundamental to appropriate intraoperative surgical visualization. SUMMARY This chapter delineates medical, technical and technological means - preoperatively and intraoperatively - to achieve optimized visualization of the surgical field in ESS.
Collapse
Affiliation(s)
- Ashoke R Khanwalkar
- Department of Otolaryngology - Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | |
Collapse
|
14
|
Yang W, Wang G, Li H, Yan X, Ren Y, Wang Y, Hu H, Song X, Wan Y, Wang C, Lou H, Huang Q, Wang X, Zhang L. The 15° reverse Trendelenburg position can improve visualization without impacting cerebral oxygenation in endoscopic sinus surgery-A prospective, randomized study. Int Forum Allergy Rhinol 2020; 11:993-1000. [PMID: 33283449 DOI: 10.1002/alr.22734] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 10/01/2020] [Accepted: 10/21/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND In this study we compared intraoperative bleeding and regional cerebral oxygenation in patients with different degrees of the reverse Trendelenburg position (RTP) during endoscopic sinus surgery (ESS). METHODS In total, 120 patients with chronic rhinosinusitis treated by ESS were randomly assigned to the following 4 groups: a horizontal position (HP) group, and 5°, 10°, and 15° RTP (5-RTP, 10-RTP, and 15-RTP, respectively) groups. The primary outcome was the Boezaart grading scale (BS). The cerebral oxygen saturation (ScO2 ), total blood loss, numerical rating scale (NRS) scores, and complications were also recorded. RESULTS The median BS values in the HP, 5-RTP, 10-RTP, and 15-RTP groups were 2.0, 2.0, 2.1, and 1.7, respectively. Multiple pairwise comparisons of the BS showed significant differences between the 15-RTP group and the other 3 groups (HP, 5-RTP, and 10-RTP). Regarding the NRS and bleeding rate, significant differences were found between the HP and 15-RTP groups. No difference was found in ScO2 among the 4 groups, and no cerebral desaturation events occurred in any group. No complications, including vital organ (heart, brain, and kidney) dysfunction problems, were reported in this study during hospitalization. CONCLUSION Compared with HP, 5-RTP, and 10-RTP, 15-RTP can improve visual clarity during ESS, and ScO2 is not affected by the degree of RTP. No cerebral deoxygenation or vital organ dysfunction was observed in this study. Therefore, we recommend 15-RTP with moderate deliberate hypotension for ESS.
Collapse
Affiliation(s)
- Wenjing Yang
- Department of Anesthesiology, Beijing TongRen Hospital, Capital Medical University, Beijing, China
| | - Guyan Wang
- Department of Anesthesiology, Beijing TongRen Hospital, Capital Medical University, Beijing, China
| | - He Li
- Department of Anesthesiology, Beijing TongRen Hospital, Capital Medical University, Beijing, China
| | - Xing Yan
- Department of Anesthesiology, Beijing TongRen Hospital, Capital Medical University, Beijing, China
| | - Yaoyao Ren
- Department of Anesthesiology, Beijing TongRen Hospital, Capital Medical University, Beijing, China
| | - Yue Wang
- Department of Anesthesiology, Beijing TongRen Hospital, Capital Medical University, Beijing, China
| | - Haili Hu
- Department of Anesthesiology, Beijing TongRen Hospital, Capital Medical University, Beijing, China
| | - Xiaoli Song
- Department of Anesthesiology, Beijing TongRen Hospital, Capital Medical University, Beijing, China
| | - Ying Wan
- Department of Anesthesiology, Beijing TongRen Hospital, Capital Medical University, Beijing, China
| | - Chengshuo Wang
- Department of Otolaryngology-Head and Neck Surgery, Beijing TongRen Hospital, Capital Medical University, Beijing, China
| | - Hongfei Lou
- Department of Otolaryngology-Head and Neck Surgery, Beijing TongRen Hospital, Capital Medical University, Beijing, China
| | - Qian Huang
- Department of Otolaryngology-Head and Neck Surgery, Beijing TongRen Hospital, Capital Medical University, Beijing, China
| | - Xiangdong Wang
- Department of Otolaryngology-Head and Neck Surgery, Beijing TongRen Hospital, Capital Medical University, Beijing, China
| | - Luo Zhang
- Department of Otolaryngology-Head and Neck Surgery, Beijing TongRen Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
15
|
Xu JC, Hanna G, Fong BM, Hsu FPK, Cadena G, Kuan EC. Ergonomics of Endoscopic Skull Base Surgery: A Systematic Review. World Neurosurg 2020; 146:150-155. [PMID: 33189918 DOI: 10.1016/j.wneu.2020.11.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 11/04/2020] [Accepted: 11/05/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVE There has been a significant expansion in endonasal endoscopic skull base surgery (EES) that has been used to address a wide range of intracranial and sinonasal pathologies. Although there exists a large amount of literature on approaches and patient outcomes, there is a paucity of data describing ergonomics in this field. Our goal was to evaluate and summarize the literature on ergonomics in EES. METHODS We systematically reviewed all published, peer-reviewed, English language literature in the PubMed and Web of Science databases as screened by multiple reviewers describing ergonomics as related to EES. RESULTS A total of 50 articles were found that described significant conclusions and descriptions on ergonomics in EES. We found and summarized the different technical aspects of ergonomics as pertaining to EES and provided evidence-based suggestions on operating room and surgeon setup. CONCLUSIONS There are several improvements in EES ergonomics that can decrease fatigue, improve efficiency, and overall surgeon well-being.
Collapse
Affiliation(s)
- Jordan C Xu
- Department of Neurosurgery, University of California, Irvine, Orange, California, USA
| | - George Hanna
- Department of Neurosurgery, University of California, Irvine, Orange, California, USA
| | - Brendan M Fong
- Department of Neurosurgery, University of California, Irvine, Orange, California, USA
| | - Frank P K Hsu
- Department of Neurosurgery, University of California, Irvine, Orange, California, USA
| | - Gilbert Cadena
- Department of Neurosurgery, University of California, Irvine, Orange, California, USA
| | - Edward C Kuan
- Department of Neurosurgery, University of California, Irvine, Orange, California, USA; Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, USA.
| |
Collapse
|
16
|
Iftikhar H, Ahmed SK, Abbas SA, Ikram M, Mustafa K, Das JK. Optimum Degree of Head Elevation/Reverse Trendelenburg Position for Sinus Surgery: Systematic Review. Am J Rhinol Allergy 2020; 35:302-307. [DOI: 10.1177/1945892420954794] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background This review aims to evaluate the effect of Reverse Trendelenburg Position (RTP) on bleeding and Boezaart score and to determine the optimum degree of head elevation through a systematic review and meta-analysis. Methodology: We conducted a systematic review according to PRISMA guidelines and a literature search was performed on PubMed, Web of Science, Cochrane, Dental and Oral Science, Google scholar and Clinicaltrials.gov and included randomized controlled trials (RCTs) in English language only. We extracted all relevant data and conducted quality assessment using Cochrane risk of Bias tool (Version 2). We also performed quality assessment of the outcomes using GRADE. Meta-analysis for all the outcomes using conducted on RevMan version 5.3. Results The search identified 629 articles and three RCTs that met our inclusion criteria. Two were included in the meta-analysis. A total of 124 patients were assessed for bleeding during sinus surgery and there was a significant reduction in total blood loss in RTP (10–15°) when compared to horizontal position by 134 ml (Mean Difference (MD): −134.23; 95% confidence interval (CI): −184.13 to −67.27). RTP also had a significant reduction in bleeding per minute by 1.07 ml/min (MD: −1.07; 95%CI: (−1.69 to −0.44), while the Boezaart score was significantly lower in the RTP group (MD: −0.69; 95%CI: −0.94 to −0.43) when compared to horizontal position. Conclusion Though with limited evidence RTP for ESS reduces total blood loss, blood loss per minute and improves visualization. Further studies are needed to assess the actual impact and optimal degree of head elevation.
Collapse
Affiliation(s)
- Haissan Iftikhar
- Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan
| | | | - Syed Akbar Abbas
- Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan
| | - Mubasher Ikram
- Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan
| | - Khawaja Mustafa
- Faculty of Health Sciences Library, Aga Khan University Medical College, Karachi, Pakistan
| | - Jai K. Das
- Division of Women and Child Health, Aga Khan University, Karachi, Pakistan
| |
Collapse
|
17
|
Hanson M, Li H, Geer E, Karimi S, Tabar V, Cohen MA. Perioperative management of endoscopic transsphenoidal pituitary surgery. World J Otorhinolaryngol Head Neck Surg 2020; 6:84-93. [PMID: 32596652 PMCID: PMC7296486 DOI: 10.1016/j.wjorl.2020.01.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 01/19/2020] [Indexed: 11/12/2022] Open
Abstract
The contemporary embrace of endoscopic technology in the approach to the anterior skull base has altered the perioperative landscape for patients requiring pituitary surgery. Utility of a multi-disciplinary unit in management decisions facilitates the delivery of optimal care. Evolution of technology and surgical expertise in pituitary surgery mandates ongoing review of all components of the care central to these patients. The many areas of potential variability in the pre, intra and post-operative timeline of pituitary surgery are readily identifiable. Core undertakings and contemporary controversies in the peri-operative management of patients undergoing endoscopic transsphenoidal pituitary surgery are assessed against the available literature with a view to providing guidance for the best evidence-based practice.
Collapse
Affiliation(s)
- Martin Hanson
- Multidisciplinary Pituitary and Skull Base Tumour Program, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, USA
| | - Hao Li
- Multidisciplinary Pituitary and Skull Base Tumour Program, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, USA
| | - Eliza Geer
- Multidisciplinary Pituitary and Skull Base Tumour Program, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, USA
| | - Sasan Karimi
- Multidisciplinary Pituitary and Skull Base Tumour Program, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, USA
| | - Viviane Tabar
- Multidisciplinary Pituitary and Skull Base Tumour Program, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, USA
| | - Marc A Cohen
- Multidisciplinary Pituitary and Skull Base Tumour Program, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, USA
| |
Collapse
|
18
|
Omura K, Hosokawa Y, Nomura K, Aoki S, Tochigi K, Miyashita K, Tanaka Y, Otori N, Kojima H. Effect of gauze placement soaked with adrenaline at suprabullar recess on hemostasis during endoscopic sinus surgery: A randomized controlled trial. Head Neck 2020; 42:2397-2404. [PMID: 32385867 DOI: 10.1002/hed.26243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 03/09/2020] [Accepted: 04/22/2020] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Topical application of vasoconstrictors is necessary for endoscopic sinus surgery (ESS) for a bloodless surgical view and reduced intraoperative bleeding. We aimed to verify the effectiveness of gauze placement soaked with adrenaline at suprabullar recess, where the anterior ethmoidal artery exists, on hemostasis during ESS. METHODS A randomized, double-blinded trial was carried out for 26 patients receiving ESS. At the beginning of the surgery, gauze soaked with 2% lidocaine with or without 1:10 000 adrenaline was placed at the suprabullar recess for 8 minutes. Estimated blood loss, surgical field score, and operation time were compared between the two groups. RESULTS Estimated blood loss and surgical field score were significantly smaller in the adrenaline group than in the no adrenaline group. Operation time was not significantly different between the two groups. CONCLUSION Gauze placement soaked with adrenaline at suprabullar recess reduces estimated blood loss and clears the surgical field during ESS.
Collapse
Affiliation(s)
- Kazuhiro Omura
- Department of Otolaryngology, The Jikei University School of Medicine, Tokyo, Japan.,Department of Otolaryngology, Dokkyo Medical University Saitama Medical Center, Koshigaya-shi, Saitama, Japan
| | - Yu Hosokawa
- Department of Otolaryngology, The Jikei University School of Medicine, Tokyo, Japan.,Department of Otolaryngology, Dokkyo Medical University Saitama Medical Center, Koshigaya-shi, Saitama, Japan
| | - Kazuhiro Nomura
- Department of Otolaryngology, Tohoku Kosai Hospital, Sendai-shi, Miyagi, Japan
| | - Satoshi Aoki
- Department of Otolaryngology, Dokkyo Medical University Saitama Medical Center, Koshigaya-shi, Saitama, Japan
| | - Kosuke Tochigi
- Department of Otolaryngology, Dokkyo Medical University Saitama Medical Center, Koshigaya-shi, Saitama, Japan
| | - Keisuke Miyashita
- Department of Otolaryngology, Dokkyo Medical University Saitama Medical Center, Koshigaya-shi, Saitama, Japan
| | - Yasuhiro Tanaka
- Department of Otolaryngology, Dokkyo Medical University Saitama Medical Center, Koshigaya-shi, Saitama, Japan
| | - Nobuyoshi Otori
- Department of Otolaryngology, The Jikei University School of Medicine, Tokyo, Japan
| | - Hiromi Kojima
- Department of Otolaryngology, The Jikei University School of Medicine, Tokyo, Japan
| |
Collapse
|
19
|
Eliason MJ. Estimated versus actual; The accuracy of accounting for blood loss during endoscopic sinus surgery. Am J Otolaryngol 2020; 41:102342. [PMID: 31735445 DOI: 10.1016/j.amjoto.2019.102342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 11/11/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE Endoscopic sinus surgery (ESS) is the mainstay for chronic inflammatory and neoplastic sinonasal process and as a result many modalities have been studied to minimize blood loss and patient morbidity and to maximize intraoperative visualization. However, often conclusions of actual blood loss are based on surgeons' estimations without ever actually assessing the accuracy of these estimations. The objective of this study was to determine the accuracy of intraoperative blood loss estimates by attending otolaryngology surgeons among patients undergoing ESS. MATERIALS AND METHODS After obtaining institutional review board approval, data were collected on six surgeons performing ESS at a military academic medical center for 21 surgical cases. Specifically, both hourly and end-of-case total "estimated" (EBL) and "calculated actual" (ABL) blood loss values were recorded and compared statistically. Surgeons were blinded to the results until after all data were collected. RESULTS The difference between mean EBL and ABL was 62.5 ml and was statistically significant (p = .007, Power 86.2%). EBL lagged ABL for both hourly intervals during a surgical case and the total end-of-surgery values. CONCLUSION The surgeons studied had EBL that were statistically significantly less than ABL both at hourly intervals during the surgery and at the conclusion of the case. As a result there exists potential for adverse consequences in clinical care and in efforts in medical research/advancement.
Collapse
|
20
|
Miller C, Humphreys IM, Davis GE. Effect of Over the Counter Ibuprofen Dosing after Sinus Surgery for Chronic Rhinosinusitis: A Prospective Cohort Pilot Study. Ann Otol Rhinol Laryngol 2020; 129:677-683. [PMID: 32028782 PMCID: PMC10163897 DOI: 10.1177/0003489420906179] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Introduction: Management of pain following endoscopic sinus surgery (ESS) often involves intermittent use of opioid medications. Given the current opioid crisis, many surgeons aim to minimize opioid prescriptions. However, surgeons often avoid the use of NSAIDs following ESS out of concern for increased bleeding risk. We sought to evaluate the effectiveness and safety of over the counter dosing of ibuprofen on pain and bleeding rates following ESS. Methods: Prospective cohort pilot study of patients undergoing ESS. Patients self-selected either control arm (acetaminophen and PRN oxycodone) or intervention arm (alternating ibuprofen with acetaminophen, and PRN oxycodone). Outcome measures included pain (10-point visual analog scale [VAS]), bleeding rate (10-point VAS), and number of opiate pills consumed. Results: Thirty-nine patients completed the study (15 control and 24 intervention). Overall, patients in the intervention arm reported decreased pain levels at days 1 (−0.9 [95%CI: −2.2, 0.5], 3 (−0.9 [95%CI: −2.3, 0.5]), and 7 (−0.6 [95%CI: −1.8, 0.6]), as well as decreased postoperative bleeding at those same days −0.9 [95%CI: −2.1, 0.4], −0.9 [95%CI: −2.1, 0.4], and −0.7 [95% CI: −1.2, −0.7], compared to controls. Opiate consumption was similar between groups with patients consuming on average four opiate pills (oxycodone 5 mg). Conclusions: Over the counter dosing of ibuprofen along with acetaminophen may yield better pain control after sinus surgery compared to acetaminophen alone. Additionally, there was no significant difference in epistaxis in the ibuprofen cohort compared to the cohort who did not take ibuprofen. Furthermore, this study showed very few opioid pills were consumed after routine ESS regardless of pain regimen prescribed. A larger trial is needed to make definitive statements on safety and efficacy. Level of Evidence: 2b
Collapse
Affiliation(s)
- Craig Miller
- Department of Otolaryngology—Head & Neck Surgery, University of Washington, Seattle, WA, USA
| | - Ian M. Humphreys
- Department of Otolaryngology—Head & Neck Surgery, University of Washington, Seattle, WA, USA
| | - Greg E. Davis
- Department of Otolaryngology—Head & Neck Surgery, University of Washington, Seattle, WA, USA
| |
Collapse
|
21
|
Shah A, Palmer AJR, Klein AA. Strategies to minimize intraoperative blood loss during major surgery. Br J Surg 2020; 107:e26-e38. [DOI: 10.1002/bjs.11393] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 09/12/2019] [Indexed: 12/19/2022]
Abstract
Abstract
Background
Reducing operative blood loss improves patient outcomes and reduces healthcare costs. The aim of this article was to review current surgical, anaesthetic and haemostatic intraoperative blood conservation strategies.
Methods
This narrative review was based on a literature search of relevant databases up to 31 July 2019 for publications relevant to reducing blood loss in the surgical patient.
Results
Interventions can begin early in the preoperative phase through identification of patients at high risk of bleeding. Directly acting anticoagulants can be stopped 48 h before most surgery in the presence of normal renal function. Aspirin can be continued for most procedures. Intraoperative cell salvage is recommended when anticipated blood loss is greater than 500 ml and this can be continued after surgery in certain situations. Tranexamic acid is safe, cheap and effective, and routine administration is recommended when anticipated blood loss is high. However, the optimal dose, timing and route of administration remain unclear. The use of topical agents, tourniquet and drains remains at the discretion of the surgeon. Anaesthetic techniques include correct patient positioning, avoidance of hypothermia and regional anaesthesia. Permissive hypotension may be beneficial in selected patients. Promising haemostatic strategies include use of pharmacological agents such as desmopressin, prothrombin complex concentrate and fibrinogen concentrate, and use of viscoelastic haemostatic assays.
Conclusion
Reducing perioperative blood loss requires a multimodal and multidisciplinary approach. Although high-quality evidence exists in certain areas, the overall evidence base for reducing intraoperative blood loss remains limited.
Collapse
Affiliation(s)
- A Shah
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - A J R Palmer
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - A A Klein
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, UK
| |
Collapse
|
22
|
Ahmed OG, Yu J, Choi JS, Yim MT, Yoshor D, Takashima M. Real-time hemodynamic effects of 1:100,000 and 1:200,000 injectable epinephrine and placement of topical 1:1000 epinephrine pledgets in patients undergoing endoscopic sinus and skull-base surgery: a randomized, prospective study. Int Forum Allergy Rhinol 2019; 10:141-146. [PMID: 31816191 DOI: 10.1002/alr.22493] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 10/08/2019] [Accepted: 10/16/2019] [Indexed: 11/08/2022]
Abstract
BACKGROUND Intranasal injection of epinephrine and placement of topical epinephrine pledgets are methods to improve visualization during endoscopic sinonasal surgery. Studies comparing the hemodynamic effects of these vasoconstrictors using intraoperative arterial line monitoring are lacking. METHODS Twenty-eight patients undergoing endoscopic skull-base surgery were enrolled in a prospective, randomized study. Patients were randomized to have either 2 mL of 1:100,000 or 2 mL of 1:200,000 epinephrine injected intranasally. Hemodynamic parameters, including pulse, systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP), were collected using intraoperative arterial line monitoring for 5 minutes. Afterward, 1:1000 topical epinephrine-soaked pledgets were placed in both groups, and the same parameters were collected for another 5 minutes. RESULTS There was no statistical difference in change in pulse, SBP, DBP, and MAP between the 1:100,000 and 1:200,000 epinephrine groups. However, epinephrine injections did cause an increase in all hemodynamic parameters when compared with baseline (p < 0.05). Topical epinephrine pledgets placed after injection of epinephrine did not have any significant hemodynamic effects, except for 2 of 28 patients who had a >75-mmHg increase in SBP. No preoperative characteristics were identified that predicted sensitivity to epinephrine. CONCLUSION There is no statistical difference in changes in hemodynamic parameters between injecting epinephrine 1:100,000 compared with 1:200,000 during endoscopic sinonasal surgery. In a subset of patients, placement of topical 1:1000 epinephrine pledgets had significant hemodynamic elevation requiring intervention and thus should be used judiciously depending on patient comorbidities.
Collapse
Affiliation(s)
- Omar G Ahmed
- Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, TX
| | - Justin Yu
- Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, TX
| | - Jonathan S Choi
- Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, TX
| | - Michael T Yim
- Department of Otolaryngology-Head and Neck Surgery, University of Utah Health, Salt Lake City, UT
| | - Daniel Yoshor
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX
| | - Masayoshi Takashima
- Department of Otolaryngology-Head & Neck Surgery, Houston Methodist Hospital, Houston, TX
| |
Collapse
|
23
|
Escamilla Y, Cardesín A, Samara L, López S, Izquierdo A, Fradera M, Vives R, Bernal-Sprekelsen M, Pontes C. Randomized clinical trial to compare the efficacy to improve the quality of surgical field of hypotensive anesthesia with clonidine or dexmedetomidine during functional endoscopic sinus surgery. Eur Arch Otorhinolaryngol 2019; 276:3095-3104. [DOI: 10.1007/s00405-019-05575-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Accepted: 07/16/2019] [Indexed: 12/18/2022]
|
24
|
Efsun Ozgunay S, Ozmen S, Karasu D, Yilmaz C, Taymur I. The Effect of Hypnosis on Intraoperative Hemorrhage and Postoperative Pain in Rhinoplasty. Int J Clin Exp Hypn 2019; 67:262-277. [PMID: 31251709 DOI: 10.1080/00207144.2019.1612670] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
This prospective, randomized study investigated the effects of preoperative hypnosis on hemorrhage and pain in open septorhinoplasty (SRP). Twenty-two patients undergoing SRP under general anesthesia were included and equally divided into two groups. Patients in the hypnosis group (HG) received a total of three sessions of hypnotic induction. The first two sessions occurred 3 days and 1 day prior to surgery, respectively, and the last session was in the hospital the day of surgery. The other 11 patients constituted the control group (CG). Compared with the CG, the HG's intraoperative use of total remifentanil and the visual analog scale scores at the 2nd and 3rd postoperative hours were significantly lower (p < .05). Hypnosis did not affect the quality of the surgical field. However, preoperative use of hypnosis decreased intraoperative remifentanil requirements and postoperative pain.
Collapse
Affiliation(s)
- Seyda Efsun Ozgunay
- a Department of Anesthesiology and Reanimation , University of Health Sciences Bursa Yuksek Ihtisas Research and Education Hospital , Bursa , Turkey
| | - Suay Ozmen
- b Department of Otorhinolaryngology , University of Health Sciences Bursa Yuksek Ihtisas Training and Research Hospital , Bursa , Turkey
| | - Derya Karasu
- a Department of Anesthesiology and Reanimation , University of Health Sciences Bursa Yuksek Ihtisas Research and Education Hospital , Bursa , Turkey
| | - Canan Yilmaz
- a Department of Anesthesiology and Reanimation , University of Health Sciences Bursa Yuksek Ihtisas Research and Education Hospital , Bursa , Turkey
| | - Ibrahim Taymur
- c Department of Psycihiatry , University of Health Sciences Bursa Yuksek Ihtisas Training and Research Hospital , Bursa , Turkey
| |
Collapse
|
25
|
Alsaleh S, Manji J, Javer A. Optimization of the Surgical Field in Endoscopic Sinus Surgery: an Evidence-Based Approach. Curr Allergy Asthma Rep 2019; 19:8. [PMID: 30712131 DOI: 10.1007/s11882-019-0847-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The advent of endoscopic sinus surgery (ESS) has enabled the development of minimally invasive surgical procedures in Rhinology. However, proficiency with ESS techniques can still be hampered by poorly controlled bleeding limiting visibility of the surgical field (VSF). This can lead to increased operating time and, more importantly, increased risk of major and minor complications. To optimize the VSF and mitigate the risk of complications, many strategies have been explored. RECENT FINDINGS This is a narrative review of the relative risks and benefits of pre- and intra-operative interventions aimed at optimizing intraoperative conditions during ESS. The value of these interventions is determined based on their impact on intraoperative blood loss, time of surgery, and the VSF, and weighed against their adverse event profile. This review provides a comprehensive overview of the evidence relating to the safety and efficacy of interventions used to improve intraoperative conditions during ESS.
Collapse
Affiliation(s)
- Saad Alsaleh
- Otolaryngology - Head and Neck Surgery Department, College of Medicine, King Saud University Medical City, PO Box 245, Riyadh, 11411, Saudi Arabia.
- St. Paul's Sinus Centre, Vancouver, BC, Canada.
| | - Jamil Manji
- St. Paul's Sinus Centre, Vancouver, BC, Canada
| | - Amin Javer
- St. Paul's Sinus Centre, Vancouver, BC, Canada
| |
Collapse
|
26
|
Kim DH, Kang H, Hwang SH. The Effect of Sphenopalatine Block on the Postoperative Pain of Endoscopic Sinus Surgery: A Meta-analysis. Otolaryngol Head Neck Surg 2018; 160:223-231. [DOI: 10.1177/0194599818805673] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives The use of sphenopalatine ganglion block (SPGB) with a local anesthetic to decrease postoperative pain after endoscopic sinus surgery (ESS) is controversial. We investigated the role of a perioperative SPB to minimize postoperative pain related to ESS in patients with chronic sinusitis through a systematic review of the relevant literature. Data Sources PubMed, SCOPUS, Google Scholar, Embase, and the Cochrane Register of Controlled Trials. Review Methods We screened the relevant literature published before June 2018. Eight articles that compared perioperative SPGB (treatment group) with a placebo or no treatment (control group) were included for this analysis of the outcomes, which included perioperative morbidities in ESS. For quantitative variables, the standardized mean difference was applied to standardize and summate the results of the studies, and the odds ratio was used in outcome of incidence analysis. Results Intraoperative bleeding ( P < .0001), postoperative pain ( P = .0001), nausea and vomiting ( P = .0117), and recovery from sedation ( P < .0001) in the treatment group were significantly reduced compared with the control group. No significant adverse effects were reported in the enrolled studies. In subgroup analyses according to the SPGB approach (transoral or transnasal), the transnasal approach showed higher positive effects on intraoperative bleeding and postoperative pain compared to the transoral approach. Conclusion In our study, SPGB combined with a local anesthetic for ESS effectively reduced intra-and postoperative morbidities. This procedure showed no significant adverse effects. Given the ease and effectiveness of this procedure, the transnasal approach should be highly recommended as a routine procedure compared to the transoral approach.
Collapse
Affiliation(s)
- Do Hyun Kim
- Department of Otolaryngology–Head and Neck Surgery, Seoul St Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Haram Kang
- Department of Otolaryngology–Head and Neck Surgery, Bucheon St Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Se Hwan Hwang
- Department of Otolaryngology–Head and Neck Surgery, Bucheon St Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| |
Collapse
|
27
|
Hwang SH, Kim SW, Kim SW, Kim BG, Cho JH, Kang JM. Greater palatine canal injections reduce operative bleeding during endoscopic sinus surgery: a systematic review and meta-analysis. Eur Arch Otorhinolaryngol 2018; 276:3-10. [PMID: 30238311 DOI: 10.1007/s00405-018-5138-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 09/15/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVES The use of greater palatine canal (GPC) injections of a local anesthetic and a vasoconstrictor to decrease surgical bleeding during endoscopic sinus surgery (ESS) is controversial. We investigated the role of a preoperative GPC injection to minimize intraoperative bleeding during ESS in patients with chronic sinusitis through a meta-analysis of the relevant literature. DATA SOURCES PubMed, SCOPUS, and the Cochrane database. REVIEW METHODS We screened the relevant literature published before May of 2018. Five articles that compared the pre-operative GPC injection (treatment group) with a placebo or no treatment (control group) were included for this analysis of the outcomes, which included an endoscopic grade of nasal bleeding and intraoperative hemodynamic stability during ESS. RESULTS The endoscopic grade in the treatment group was significantly reduced when compared with the control group. No significant adverse effects were reported in the enrolled studies. The subgroup analyses of these results compared the concentrations of adrenalin (1:80,000 or 1:100,000), and adrenalin 1:80,000 showed significant effects on intraoperative bleeding when compared to adrenalin 1:100,000. CONCLUSION This study demonstrated that GPC injections of local anesthesia with 1:80,000 adrenaline for ESS effectively reduced intraoperative bleeding. Additionally, this procedure showed no significant adverse effects, such as hemodynamic instability. However, the standardized dosing needs further investigation and more trials. LEVEL OF EVIDENCE Ia.
Collapse
Affiliation(s)
- Se Hwan Hwang
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.,Department of Otolaryngology-Head and Neck Surgery, College of Medicine, Bucheon St. Mary's Hospital, The Catholic University of Korea, 327 Sosa-ro, Bucheon-si, Gyeonggi-do, 14647, Republic of Korea
| | - Sung Won Kim
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Soo Whan Kim
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Byung Guk Kim
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jin Hee Cho
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jun Myung Kang
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea. .,Department of Otolaryngology-Head and Neck Surgery, College of Medicine, Bucheon St. Mary's Hospital, The Catholic University of Korea, 327 Sosa-ro, Bucheon-si, Gyeonggi-do, 14647, Republic of Korea.
| |
Collapse
|
28
|
Ference EH, Suh JD, Tan BK, Smith SS. How often is sinus surgery performed for chronic rhinosinusitis with versus without nasal polyps? Am J Rhinol Allergy 2018; 32:34-39. [PMID: 29336288 DOI: 10.2500/ajra.2018.32.4495] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND There currently are no data on the relative frequency of endoscopic sinus surgeries (ESS) performed for chronic rhinosinusitis with nasal polyposis (CRSwNP) versus chronic rhinosinusitis without nasal polyposis (CRSsNP) in the United States. OBJECTIVES To compare the rate of surgical interventions for CRSwNP and CRSsNP. METHODS Cases identified by CPT codes were extracted from the 2009-2011 State Ambulatory Surgery Databases for California, Florida, Maryland, and New York. Patient demographics, extent of surgery, mean charges, and operating room (OR) time were compared. RESULTS A total of 97,228 ESS cases were performed in the four states; 29.3% of surgeries were for patients with CRSwNP, 66.0% of patients with CRSsNP, and 4.8% for other indications. The proportion of ESS for CRSwNP varied across states, with California having the highest percentage (34.6%) and Maryland having the lowest (26.4%) (p < 0.0001). Patients with Medicaid (33.8%) and Medicare (32.2%) had higher rates of surgery for CRSwNP compared with patients with private insurance (29.9%) (p < 0.001). Surgeons who performed a higher volume of sinus surgery compared to lower volume surgeons performed a lower percentage of surgery for CRSwNP (24.4 versus 33.5%; p < 0.001). ESS cases for CRSwNP were more extensive (relative risk of four sinus surgeries of 1.88; p < 0.0001), used image guidance more frequently (relative risk, 1.39; p < 0.0001), and were less likely to include a balloon procedure (relative risk, 0.69; p < 0.0001). Patients with CRSwNP had longer OR times (ESS that involved all four sinuses took 14 minutes longer) (p < 0.0001), but no difference in charges compared with patients with CRSsNP who underwent a similar extent of surgery. CONCLUSION Almost 30% of ESS were performed for CRSwNP, and these cases were, on average, more extensive, used more OR time, and more often used image guidance than surgeries for CRSsNP. The rate of surgery performed for CRSwNP varied based on geography, payer, and surgical volume, which indicted that patient selection impacted surgical management.
Collapse
Affiliation(s)
- Elisabeth H Ference
- From the Rick and Tina Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine of University of Southern California, Los Angeles, California
| | - Jeffrey D Suh
- Department of Head and Neck Surgery, David Geffen School of Medicine of the University of California, Los Angeles, Los Angeles, California
| | - Bruce K Tan
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Stephanie Shintani Smith
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| |
Collapse
|
29
|
Carlton DA, Govindaraj S. Anesthesia for functional endoscopic sinus surgery. Curr Opin Otolaryngol Head Neck Surg 2018; 25:24-29. [PMID: 28005566 DOI: 10.1097/moo.0000000000000322] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE OF REVIEW The present article summarizes anesthetic techniques used during functional endoscopic sinus surgery to decrease bleeding and aid in creating a clear surgical field. The applicable physiology behind these anesthetic techniques is reviewed with emphasis on the effect on bleeding and the surgical field. Deliberate hypotension, reverse Trendelenburg positioning, regional anesthesia, and cerebral monitoring are discussed. RECENT FINDINGS There are mixed data as to whether traditional inhalation anesthesia or total intravenous anesthesia is superior with respect to better surgical fields and decreased blood loss. A review of the literature tends to favor total intravenous anesthesia. Cerebral oximetry and transcranial Doppler ultrasound are emerging techniques to monitor cerebral perfusion during deliberate hypotension. SUMMARY Total intravenous anesthesia using propofol and remifentanil is the current favored technique for producing deliberate hypotension during endoscopic sinus surgery due to its hemodynamic stability and smooth rapid emergence.
Collapse
Affiliation(s)
- Daniel A Carlton
- Department of Otolaryngology - Head and Neck Surgery at Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | |
Collapse
|
30
|
Use of α 2-Adrenergic Agonists to Improve Surgical Field Visibility in Endoscopy Sinus Surgery: A Systematic Review of Randomised Controlled Trials. Clin Ther 2018; 40:136-149.e19. [PMID: 29268957 DOI: 10.1016/j.clinthera.2017.11.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 11/25/2017] [Accepted: 11/29/2017] [Indexed: 02/01/2023]
Abstract
PURPOSE We assessed the evidence for the use of α2-adrenergic agonists (A2AAs) in bleeding control and field quality in endoscopic sinus surgery. METHODS We systematically reviewed randomized clinical trials (RCTs) assessing A2AAs in endoscopic sinus surgery. Abstracts were reviewed by 2 investigators for eligibility, and selected articles were fully reviewed. Data on study design, population, A2AA drug and control groups, bleeding and surgical field quality outcomes, and adverse effects were extracted and synthesized. FINDINGS A total of 13 RCTs that included 896 individuals (7 double-blind trials, 5 single-blind trials, and 1 open-label trial) were selected that assessed the efficacy of clonidine (6 RCTs, 407 patients), dexmedetomidine (6 RCT, 423 patients), or both (1 RCT, 66 patients). Clonidine was compared with placebo (3 RCTs), midazolam (1 RCT), and remifentanil (2 RCTs). Dexmedetomidine was compared with esmolol (2 RCTs), remifentanil (2 RCTs), nitroglycerin and esmolol (1 RCT), and magnesium sulfate (1 RCT). Clonidine and dexmedetomidine were compared in 1 RCT. Clonidine reduced the proportion of individuals with an impaired surgical field by 23% vs placebo (number needed to treat = 4). Clonidine was better than midazolam and remifentanil in 2 trials, and dexmedetomidine was better than magnesium sulfate and esmolol in 2 trials but was not superior to esmolol, remifentanil, or nitroglycerin in 4 trials. Dexmedetomidine produced significantly better differences in bleeding outcomes versus clonidine. Adverse events were infrequent and mainly caused by hypotension or bradycardia. IMPLICATIONS RCTs consistently report that A2AAs reduce bleeding and improve surgical field quality during endoscopic sinus surgery. Adverse event reporting was often omitted in RCTs. Well-designed RCTs with appropriate sample sizes are desirable to identify the best A2AAs and confirm their potential effects on clinical outcomes.
Collapse
|
31
|
Das A, Biswas H, Mukherjee A, Basunia SR, Chhaule S, Mitra T, Halder PS, Mandal SK. Evaluation of Preoperative Flupirtine in Ambulatory Functional Endoscopic Sinus Surgery: A Prospective, Double-Blind, Randomized Controlled Trial. Anesth Essays Res 2017; 11:902-908. [PMID: 29284847 PMCID: PMC5735486 DOI: 10.4103/aer.aer_60_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background: Functional endoscopic sinus surgery (FESS) is the mainstay therapeutic management for nasal pathologies. We evaluated flupirtine, a centrally acting analgesic, for producing perfect perioperative conditions in FESS for adults in a day-care setting. Materials and Methods: Sixty-two patients (25–40 years) scheduled for FESS under general anesthesia were randomly divided into Group F (n = 31) receiving preoperative flupirtine (100 mg) and Group C (n = 31) receiving identical-looking placebo capsule per oral 60 min before induction of anesthesia. Perioperative Nasal bleeding and surgeon's satisfaction score during operation; amount and number of patients receiving fentanyl, propofol, and esmolol infusion for analgesia; maintenance of desired bispectral index (BIS) and deliberate hypotension, respectively. Postanesthesia Care Unit (PACU) and hospital stay, hemodynamic parameters, and side effects were all recorded for each patient. Results: Significantly, less number of patients and less dosage of esmolol were required (P = 0.0040 and 0.0001, respectively) in Group F as compared to that in Group C. Again, number of patients requiring fentanyl and dosage of the same drug was significantly lower in Group F. Dose of propofol for the maintenance of BIS was significantly lower in Group F. However, the duration of controlled hypotension was almost similar in both groups. Group F patients suffered significantly less nasal bleeding and surgeon's satisfaction score was also high in this group. Discharge time from PACU and hospital was similar between two groups without any appreciable side effects. Conclusion: Flupirtine as a premedication found to be providing more favorable perioperative hemodynamic conditions, analgesia and thus allowing less nasal bleeding as well as more surgeons’ satisfaction score.
Collapse
Affiliation(s)
- Anjan Das
- Department of Anaesthesiology, College of Medicine and Sagore Dutta Hospital, Kolkata, West Bengal, India
| | - Hirak Biswas
- Department of Anaesthesiology, College of Medicine and Sagore Dutta Hospital, Kolkata, West Bengal, India
| | - Anindya Mukherjee
- Department of Anaesthesiology, N.R.S Medical College, Kolkata, West Bengal, India
| | - Sandip Roy Basunia
- Department of Anaesthesiology, Midnapore Medical College and Hospital, Midnapore, West Bengal, India
| | - Subinay Chhaule
- Department of Anaesthesiology, College of Medicine and Sagore Dutta Hospital, Kolkata, West Bengal, India
| | - Tapobrata Mitra
- Department of Anaesthesiology, Murshidabad Medical College and Hospital, Baharampur, West Bengal, India
| | - Partha Sarathi Halder
- Department of Anaesthesiology, College of Medicine and Sagore Dutta Hospital, Kolkata, West Bengal, India
| | - Subrata Kumar Mandal
- Department of Anaesthesiology, College of Medicine and Sagore Dutta Hospital, Kolkata, West Bengal, India
| |
Collapse
|
32
|
Azimuddin AF, Weitzel EK, McMains KC, Chen PG. An ergonomic assessment of operating table and surgical stool heights for seated otolaryngology procedures. ALLERGY & RHINOLOGY 2017; 8:182-188. [PMID: 29070277 PMCID: PMC5662545 DOI: 10.2500/ar.2017.8.0215] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background: Musculoskeletal injuries, such as neck and back pain, during a surgeon's career are common. However, studies on ergonomics are limited with regard to seated otolaryngologic procedures. Key elements of an ergonomic operating environment include the height of operating tables and surgical chairs. Surgeons benefit from proper support and positioning to prevent musculoskeletal injuries and reduce occupational risk. Objective: The purpose of this study was to evaluate operating table and surgical seat heights, and determine whether adjustments can be made for various surgeon physiques. Methods: Operating tables and surgical seat dimensions were measured at local hospitals, and the information was complemented by an online search of other models. Results: Five unique operating tables and five unique surgical stools were identified, both in the local hospital and in a search on the Internet. Of available tables, the greatest range was 63.5–124.5 cm, which reaches above the maximum suggested working height of 76.2 cm. The surgical stool with the widest range was adjustable from heights of 50.8–72.4 cm. This combination of operative table and surgical stool provided the greatest range of heights. Conclusion: Of the available tables and stools measured, the combination of surgical table with a range of 63.5–125.7 cm and surgical stool with a range of 50.8–72.4 cm provided the greatest versatility for diverse physician heights. In ergonomic terms, this combination may reduce physical fatigue and create a potentially safer working environment for seated surgeons.
Collapse
Affiliation(s)
- Anam F Azimuddin
- From the Department of Otolaryngology-Head and Neck Surgery, University of Texas Health San Antonio, San Antonio, Texas
| | - Erik K Weitzel
- Department of Surgery, San Antonio Uniformed Services Health Educational Consortium, Joint Base San Antonio, San Antonio, Texas
| | - Kevin C McMains
- Department of Surgery, San Antonio Uniformed Services Health Educational Consortium, Joint Base San Antonio, San Antonio, Texas
| | - Philip G Chen
- From the Department of Otolaryngology-Head and Neck Surgery, University of Texas Health San Antonio, San Antonio, Texas
| |
Collapse
|
33
|
Abstract
Endoscopic sinus approach has become one of the most common surgical techniques for endoscopic sinus and skull base surgery. Anesthetic management has an important impact on the overall patient management, from the preoperative assessment and management to the quality of the surgical field and the postoperative recovery. Hemostasis is critical for adequate anatomical endoscopic visualization. Mild controlled hypotension seems to improve the visibility of the surgical field. Reduction of intraoperative bleeding should be considered during the treatment planning. Preoperative preparations include the optimization of comorbidities and cessation of drugs that may inhibit coagulation.
Collapse
Affiliation(s)
- Martha Cordoba Amorocho
- Department of Anesthesiology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, 243 Charles Street, Boston, MA 02114, USA; Department of Anesthesiology and Critical Care, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
| | - Iuliu Fat
- Department of Anesthesiology, Harbor Hospital, 3001 South Hanover Street, Baltimore, MD 21225, USA
| |
Collapse
|
34
|
Abstract
Intraoperative bleeding during endoscopic sinus surgery poses an additional dimension to an already technically challenging surgical approach because of the narrow sinonasal surgical field, single working hand, and the use of endoscopic instruments. Poor visualization is one of the most important factors that increase the risk of intraoperative complications such as inadvertent injury to major vessels and nerves, and incomplete surgery. This article provide a logical approach to improving the surgical field, minimizing risk of inadvertent vascular injury, and managing intraoperative bleeding.
Collapse
Affiliation(s)
- Harshita Pant
- Department of Otolaryngology, Head and Neck Surgery, University of Adelaide School of Medicine, Frome Road, Adelaide, SA 5005, Australia.
| |
Collapse
|
35
|
Abstract
PURPOSE OF REVIEW Optimization of the surgical field involves a complex interplay of many factors. Although it is agreed that hemostasis is critical to safe, efficient, and successful sinus surgery, a lack of consensus exists as to the best way to achieve it. This review examines the current body of evidence supporting many of the practices surgeons believe to influence hemostasis. RECENT FINDINGS Although many of the practices discussed in this article have long been considered to influence hemostasis, it is not until recently that high-level evidence supporting their use has been available. Well designed studies now exist supporting the preoperative use of oral steroids in polyp patients, the importance of adequate reverse trendelenburg positioning, the use of flexible laryngeal mask ventilation during general anesthesia, and the increased safety and comparable efficacy of topical epinephrine over other topical and injectable agents. Controversy still exists as to the ideal method of achieving controlled hypotensive anesthesia, although new evidence has emerged as to what hemodynamic parameters should be adhered to, to reduce the risk of cerebral hypoperfusion. SUMMARY Numerous factors influence hemostasis and so it is important that ENT surgeons have a sound understanding of the evidence supporting their everyday surgical practice. Improved standardization of scoring and reporting of bleeding may increase the power of research studies to draw more definitive conclusions about the role that certain factors have on hemostasis.
Collapse
|
36
|
Michael P, Farid M, Kwok M, O'Leary S. Routine nasal packing versus no nasal packing following functional endoscopic sinus surgery. Hippokratia 2016. [DOI: 10.1002/14651858.cd011587.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Philip Michael
- Royal Victorian Eye and Ear Hospital/University of Melbourne; Department of Otolaryngology; 32 Gisborne Street Melbourne Australia 3122
| | | | - Matthew Kwok
- Western Hospital; Department of Otolaryngology; Melbourne Australia
| | - Stephen O'Leary
- Royal Victorian Eye and Ear Hospital/University of Melbourne; Department of Otolaryngology; 32 Gisborne Street Melbourne Australia 3122
| |
Collapse
|
37
|
Stokken JK, Halderman A, Recinos PF, Woodard TD, Sindwani R. Strategies for Improving Visualization During Endoscopic Skull Base Surgery. Otolaryngol Clin North Am 2016; 49:131-40. [PMID: 26614833 DOI: 10.1016/j.otc.2015.09.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The nasal cavity has a robust vascular supply, and bleeding is a primary obstacle to the minimally invasive skull base technique. Venous bleeding, including the cavernous sinus, can be managed with various techniques using hemostatic materials and pressure. A thorough understanding of the skull base vascular anatomy is vital for avoiding injury to major arteries and having confidence to control venous bleeding to optimize the endoscopic view and tumor resection.
Collapse
Affiliation(s)
- Janalee K Stokken
- Department of Otolaryngology, Head and Neck Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Ashleigh Halderman
- Section of Rhinology, Sinus and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue/A71, Cleveland, OH 44195, USA
| | - Pablo F Recinos
- Section of Rhinology, Sinus and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue/A71, Cleveland, OH 44195, USA; Minimally Invasive Cranial Base and Pituitary Surgery Program, Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Troy D Woodard
- Section of Rhinology, Sinus and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue/A71, Cleveland, OH 44195, USA; Minimally Invasive Cranial Base and Pituitary Surgery Program, Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Raj Sindwani
- Section of Rhinology, Sinus and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue/A71, Cleveland, OH 44195, USA; Minimally Invasive Cranial Base and Pituitary Surgery Program, Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
| |
Collapse
|
38
|
Mangussi-Gomes J, Beer-Furlan A, Balsalobre L, Vellutini EAS, Stamm AC. Endoscopic Endonasal Management of Skull Base Chordomas: Surgical Technique, Nuances, and Pitfalls. Otolaryngol Clin North Am 2016; 49:167-82. [PMID: 26614836 DOI: 10.1016/j.otc.2015.09.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Chordoma is a rare primary bone tumor derived from transformed notochord remnants. It has a local aggressive behavior and high recurrence rates. Treatment of skull base chordomas is complex and challenging. Control of the disease relies mainly on surgical excision of the tumor, sometimes followed by high-dose radiation therapy. The main surgical goal is to achieve maximal tumor removal with minimal morbidity. Development of the expanded endoscopic endonasal approach has improved surgical and prognostic results of skull base chordomas. This article highlights important aspects of approach selection, technique, and nuances of surgical management of this tumor.
Collapse
Affiliation(s)
- João Mangussi-Gomes
- São Paulo Skull Base Center, Rua Afonso Brás, 525, cj. 13, São Paulo 04511-011, Brazil; São Paulo ENT Center, Edmundo Vasconcelos Hospital, Rua Afonso Brás, 525, cj. 13, São Paulo 04511-011, Brazil
| | - André Beer-Furlan
- São Paulo Skull Base Center, Rua Afonso Brás, 525, cj. 13, São Paulo 04511-011, Brazil; DFVneuro Neurosurgical Group, Rua Dona Adma Jafet, 74, cj.121, São Paulo 01308-050, Brazil
| | - Leonardo Balsalobre
- São Paulo Skull Base Center, Rua Afonso Brás, 525, cj. 13, São Paulo 04511-011, Brazil; São Paulo ENT Center, Edmundo Vasconcelos Hospital, Rua Afonso Brás, 525, cj. 13, São Paulo 04511-011, Brazil
| | - Eduardo A S Vellutini
- São Paulo Skull Base Center, Rua Afonso Brás, 525, cj. 13, São Paulo 04511-011, Brazil; DFVneuro Neurosurgical Group, Rua Dona Adma Jafet, 74, cj.121, São Paulo 01308-050, Brazil
| | - Aldo C Stamm
- São Paulo Skull Base Center, Rua Afonso Brás, 525, cj. 13, São Paulo 04511-011, Brazil; São Paulo ENT Center, Edmundo Vasconcelos Hospital, Rua Afonso Brás, 525, cj. 13, São Paulo 04511-011, Brazil.
| |
Collapse
|
39
|
Hwang SH, Seo JH, Joo YH, Kang JM. Does the Preoperative Administration of Steroids Reduce Intraoperative Bleeding during Endoscopic Surgery of Nasal Polyps? Otolaryngol Head Neck Surg 2016; 155:949-955. [PMID: 27554509 DOI: 10.1177/0194599816663455] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 06/02/2016] [Accepted: 07/19/2016] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Corticosteroids are frequently used in a range of otorhinolaryngologic conditions due to their anti-inflammatory and antiedematous properties. In this meta-analysis, we aimed to assess the role of preoperative steroids for attenuating intraoperative bleeding during endoscopic sinus surgery among patients with nasal polyps. DATA SOURCES PubMed, SCOPUS, EMBASE, the Web of Science, and Cochrane database. METHODS Literature was screened from January 1980 to January 2016. Five articles comparing patients who were preoperatively administered steroids (steroid groups) with patients who received a placebo or no treatment (control group) were included for analysis, which encompassed intraoperative bleeding, endoscopic surgical field visibility, operative time, and side effects during endoscopic sinus surgery. RESULTS Intraoperative bleeding and operative time during endoscopic sinus surgery in the steroid group were significantly reduced as compared with the control group. Additionally, the preoperative administration of steroids had a significant effect on improving endoscopic surgical field visibility during sinus surgery. There were no significant adverse effects reported in the enrolled studies. In subgroup analyses of these results, steroids showed similar effects on intraoperative bleeding regardless of administration type (topical or systemic). CONCLUSION This study demonstrated that the preoperative administration of steroids in patients with nasal polyps could effectively reduce intraoperative bleeding. However, the duration of treatment and dosing standard require further investigation, and more trials need to be included.
Collapse
Affiliation(s)
- Se Hwan Hwang
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jae Hyun Seo
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Young Hoon Joo
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jun Myung Kang
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| |
Collapse
|
40
|
The Effect of Patient Positioning on Amount of Intraoperative Bleeding in Rhinoplasty: A Randomized Controlled Trial. Aesthetic Plast Surg 2016; 40:453-7. [PMID: 27225876 DOI: 10.1007/s00266-016-0653-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Accepted: 05/05/2016] [Indexed: 01/09/2023]
Abstract
BACKGROUND There is a rich blood flow to the mucosa in the nasal region. In rhinoplasty, surgical procedures are performed in a narrow and confined space. So bleeding during surgery reduces visibility which can complicate the procedure. This study investigated the effects of the patient position on amount of intraoperative bleeding during surgical procedures. PATIENTS AND METHODS This randomized controlled trial was conducted on 71 patients who underwent elective rhinoplasty. The patients were operated on in three groups. Group 1 consisted of 23 patients who were operated on in the supine position; Group 2 included 28 patients who were operated on using a 15° angle reverse Trendelenburg position; Group 3 consisted of 20 patients who were operated on at a 20° angle reverse Trendelenburg position. RESULTS There were statistically significant differences between the groups in regard to surgeon satisfaction and the amount of intraoperative bleeding. The amount of intraoperative bleeding in Group 1 was significantly higher than those of Groups 2 and 3, and surgeon satisfaction was lower. CONCLUSIONS Reverse Trendelenburg position reduces intraoperative bleeding in rhinoplasty patients while facilitating the procedure compared to the supine position. Surgery at a 15° angle reverse Trendelenburg position provides the optimum working conditions by both significantly reducing intraoperative bleeding and allowing for comfortable conditions for the surgeon. LEVEL OF EVIDENCE I 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 .
Collapse
|
41
|
Korkmaz H, Yao W, Korkmaz M, Bleier BS. Benefit of Preoperative Oral Steroids during Sinus Surgery when Utilizing Concentrated Topical Epinephrine. ORL J Otorhinolaryngol Relat Spec 2016; 78:216-22. [PMID: 27383647 DOI: 10.1159/000446806] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 05/13/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS Oral steroids have been advocated in the preoperative setting as a means of reducing intraoperative blood loss and surgical time during sinus surgery. The purpose of this study was to analyze the impact of preoperative oral steroid administration on intraoperative bleeding and surgical duration when coupled with concentrated topical epinephrine. METHODS The medical records of 302 patients who underwent bilateral 'full house' sinus surgery were reviewed. Concentrated topical epinephrine and inhalational anesthesia was used in all patients. Surgical duration and estimated blood loss were compared between the preoperative steroid-exposed and steroid-naive groups. χ2 and Student's t tests were used for statistical analysis. RESULTS One hundred and forty-two patients were exposed to steroid, while the remaining 160 were steroid naive. No significant differences were found with respect to surgical time between the steroid-exposed (96.91 ± 25.97 min) and steroid-naive patients (91.24 ± 32.29 min, p = 0.100). The steroid-exposed group demonstrated a marginally increased blood loss (66.03 ± 55.81 ml) as compared to steroid-naive patients (55.00 ± 38.71 ml, p = 0.048). CONCLUSION When coupled with intraoperative concentrated topical epinephrine use, preoperative oral steroid administration provides no clinically significant benefit with respect to reduced intraoperative bleeding or surgical duration.
Collapse
Affiliation(s)
- Hakan Korkmaz
- Otorhinolaryngology Department, Ordu University Faculty of Medicine, Ordu, Turkey
| | | | | | | |
Collapse
|
42
|
Halderman AA, Sindwani R, Woodard TD. Hemorrhagic Complications of Endoscopic Sinus Surgery. Otolaryngol Clin North Am 2016; 48:783-93. [PMID: 26318796 DOI: 10.1016/j.otc.2015.05.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Major complications during endoscopic sinus surgery are rare and occur in 0.36% to 3.1% of patients. Postoperative hemorrhage accounts for 23% to 39% of complications. Despite being rare, major hemorrhage can be serious for the patient. This article discusses hemorrhagic complications during and following endoscopic sinus surgery, focusing on a review of the surgical anatomy, common pitfalls to avoid, preventative measures, and management of certain catastrophic complications for which preparedness can mean the difference between life and death.
Collapse
Affiliation(s)
- Ashleigh A Halderman
- Section of Rhinology, Sinus and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue/A71, Cleveland, OH 44195, USA
| | - Raj Sindwani
- Section of Rhinology, Sinus and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue/A71, Cleveland, OH 44195, USA
| | - Troy D Woodard
- Section of Rhinology, Sinus and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue/A71, Cleveland, OH 44195, USA.
| |
Collapse
|
43
|
Ha TN, van Renen RG, Ludbrook GL, Wormald PJ. The effect of blood pressure and cardiac output on the quality of the surgical field and middle cerebral artery blood flow during endoscopic sinus surgery. Int Forum Allergy Rhinol 2016; 6:701-9. [PMID: 26879693 DOI: 10.1002/alr.21728] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Revised: 12/03/2015] [Accepted: 12/10/2015] [Indexed: 11/10/2022]
Abstract
BACKGROUND A clear surgical field is critical during endoscopic sinus surgery (ESS). Hypotensive anesthesia and cardiac output (CO) may optimize the surgical field; however, evidence of their effect on bleeding and cerebral blood flow is conflicting. The aim of this study was to evaluate the effect of blood pressure (BP) and CO on intraoperative bleeding and middle cerebral artery blood flow velocity (Vmca ) during ESS. METHODS This was a prospective randomized controlled trial. Patients undergoing ESS for chronic rhinosinusitis at a tertiary institution in 2013 were randomized to receive BP manipulation using target-controlled noradrenaline infusion during surgery to either their left or right sinuses. The contralateral side in each patient served as control. Bleeding was scored using a 0 to 10 point bleeding assessment scale (BAS, 0-10) and Vmca was measured using transcranial Doppler ultrasonography every 10 minutes or when surgically opportune, and time-matched with BP and CO. Data was analyzed using Bland-Altman methods. RESULTS A total of 105 time points were collected across a mean arterial pressure (MAP) range of 32 to 118 mmHg. Significant correlations were demonstrated between MAP and Vmca (r = 0.7, p < 0.0001), MAP and BAS (r = 0.50, p < 0.0001), CO and Vmca (r = 0.57, p < 0.0001), and CO and BAS (r = 0.42, p < 0.0001). The best surgical fields were seen at 40 to 59 mmHg MAP. However, MAP below 60 mmHg produced >50% reduction in Vmca in more than 10% of time points. CONCLUSION Balancing surgical visibility with organ perfusion remains a challenge. The results of this study show that moderate hypotension significantly improves the surgical field; however reducing BP below 60 mmHg may risk cerebral hypoperfusion.
Collapse
Affiliation(s)
- Thanh Ngoc Ha
- Department of Surgery-Otolaryngology Head and Neck Surgery, The University of Adelaide, Australia
| | | | - Guy L Ludbrook
- Discipline of Acute Care Medicine, The University of Adelaide, Australia
| | - Peter-John Wormald
- Department of Surgery-Otolaryngology Head and Neck Surgery, The University of Adelaide, Australia
| |
Collapse
|
44
|
Weber RK, Hosemann W. Comprehensive review on endonasal endoscopic sinus surgery. GMS CURRENT TOPICS IN OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY 2015; 14:Doc08. [PMID: 26770282 PMCID: PMC4702057 DOI: 10.3205/cto000123] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Endonasal endoscopic sinus surgery is the standard procedure for surgery of most paranasal sinus diseases. Appropriate frame conditions provided, the respective procedures are safe and successful. These prerequisites encompass appropriate technical equipment, anatomical oriented surgical technique, proper patient selection, and individually adapted extent of surgery. The range of endonasal sinus operations has dramatically increased during the last 20 years and reaches from partial uncinectomy to pansinus surgery with extended surgery of the frontal (Draf type III), maxillary (grade 3-4, medial maxillectomy, prelacrimal approach) and sphenoid sinus. In addition there are operations outside and beyond the paranasal sinuses. The development of surgical technique is still constantly evolving. This article gives a comprehensive review on the most recent state of the art in endoscopic sinus surgery according to the literature with the following aspects: principles and fundamentals, surgical techniques, indications, outcome, postoperative care, nasal packing and stents, technical equipment.
Collapse
Affiliation(s)
- Rainer K. Weber
- Division of Paranasal Sinus and Skull Base Surgery, Traumatology, Department of Otorhinolaryngology, Municipal Hospital of Karlsruhe, Germany
- I-Sinus International Sinus Institute, Karlsruhe, Germany
| | - Werner Hosemann
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Greifswald, Germany
| |
Collapse
|
45
|
Korkmaz H, Yao WC, Korkmaz M, Bleier BS. Safety and efficacy of concentrated topical epinephrine use in endoscopic endonasal surgery. Int Forum Allergy Rhinol 2015; 5:1118-23. [PMID: 26152362 DOI: 10.1002/alr.21590] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2015] [Revised: 05/05/2015] [Accepted: 06/03/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND Effective topical decongestion is critical for the safe performance of endoscopic endonasal surgery (EES). Despite the vasoconstriction offered by topical concentrated (1:1000) epinephrine (CE), its use has not gained widespread acceptance because of concerns over systemic absorption and its effect on blood pressure and postoperative rebound epistaxis. The purpose of this study was to examine the physiological changes in blood pressure and rate of epistaxis with use of topical CE in a variety of endoscopic nasal procedures. METHODS EES procedures using inhalational anesthesia and topical CE performed on 1140 consecutive patients (14 patients under 18 years) between 2011 and 2014 were evaluated retrospectively. Demographic data, intraoperative hemodynamic parameters, and postoperative epistaxis rates were recorded. RESULTS The mean patient age was 45.8 years (range, 5-97 years). No intraoperative cardiovascular complications related to CE use were found. Four patients (0.35%) developed postoperative epistaxis requiring intervention. The mean estimated blood loss among patients undergoing bilateral sinus surgery, skull-base surgery, and orbital decompression was (mean ± SD) 61.7 ± 51.6 mL, 60.1 ± 115 mL, and 67.9 ± 42.2 mL, respectively. The maximum mean systolic blood pressure among these groups was 108.3 ± 28.3 mmHg, 111.9 ± 27.6 mmHg, and 95.1 ± 31.7 mmHg, respectively. CONCLUSION The use of topical CE is safe when performing endoscopic endonasal procedures. CE was not associated with any intraoperative complications. The profound intraoperative vasoconstriction does not confer a higher rate of postoperative rebound epistaxis.
Collapse
Affiliation(s)
- Hakan Korkmaz
- Otorhinolaryngology Department, Faculty of Medicine, Ordu University, Ordu, Turkey
| | - William C Yao
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA
| | - Mukadder Korkmaz
- Otorhinolaryngology Department, Faculty of Medicine, Ordu University, Ordu, Turkey
| | - Benjamin S Bleier
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA
| |
Collapse
|
46
|
Vaz-Guimaraes F, Su SY, Fernandez-Miranda JC, Wang EW, Snyderman CH, Gardner PA. Hemostasis in Endoscopic Endonasal Skull Base Surgery. J Neurol Surg B Skull Base 2015. [PMID: 26225320 DOI: 10.1055/s-0034-1544119] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
William Halsted established the basic principles of modern surgical technique highlighting the importance of meticulous hemostasis and careful tissue handling. These concepts hold true today and are even more critical for endoscopic visualization, making hemostasis one of the most relevant cornerstones for the safe practice of endoscopic endonasal surgery (EES) of the skull base. During preoperative assessment, patients at higher risk for serious hemorrhagic complications must be recognized. From an anatomical point of view, EES can be grossly divided in two major components: sinonasal surgery and sellar-cranial base surgery. This division affects the choice of appropriate technique for control of bleeding that relies mainly on the source of hemorrhage, the tissue involved, and the proximity of critical neurovascular structures. Pistol-grip or single-shaft instruments constitute the most important and appropriately designed instruments available for EES. Electrocoagulation and a variety of hemostatic materials are also important tools and should be applied wisely. This article describes the experience of our team in the management of hemorrhagic events during EES with an emphasis on technical nuances.
Collapse
Affiliation(s)
- Francisco Vaz-Guimaraes
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Shirley Y Su
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Juan C Fernandez-Miranda
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Eric W Wang
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Carl H Snyderman
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States ; Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Paul A Gardner
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| |
Collapse
|
47
|
Boisson-Bertrand D, Jacquot C. [Specific anaesthetic procedures for nasal and sinus surgery]. ACTA ACUST UNITED AC 2014; 33:664-8. [PMID: 25458457 DOI: 10.1016/j.annfar.2014.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Accepted: 10/16/2014] [Indexed: 10/24/2022]
Abstract
In nasal and sinus surgery, the anaesthetist must share the operating field with the surgeon and take into account some patients' specific pathologies. Bleeding must be avoided by different means but the accurate gesture of the surgeon, added to the properties of the new anaesthetic drugs, may reduce the risk of this functional surgery.
Collapse
Affiliation(s)
- D Boisson-Bertrand
- Service d'anesthésie-réanimation, hôpital central, CHU de Nancy, 54000 Nancy, France.
| | - C Jacquot
- Service d'anesthésie-réanimation, hôpital central, CHU de Nancy, 54000 Nancy, France
| |
Collapse
|
48
|
Heller JA, DeMaria S, Govindaraj S, Lin HM, Fischer GW, Evans A, Weiner MM. Cerebral oximetry monitoring during sinus endoscopy. Laryngoscope 2014; 125:E127-31. [PMID: 25388868 DOI: 10.1002/lary.25027] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2014] [Indexed: 12/19/2022]
Abstract
OBJECTIVES/HYPOTHESIS Deliberate hypotension, reverse Trendelenburg position, and hyperventilation are techniques utilized during functional endoscopic sinus surgery to attempt to reduce surgical bleeding. These methods may predispose patients to cerebral ischemia. Cerebral oximetry has not been investigated extensively within otolaryngologic surgery. Our study sought to address the question of whether cerebral oximetry is feasible in the FESS population and evaluate whether the data provided may be useful in the assessment of cerebral perfusion. STUDY DESIGN Prospective, blinded, observational trial. METHODS We designed a prospective, blinded, observational trial of patients undergoing functional endoscopic sinus surgery using cerebral oximetry monitoring. Collected data included mean arterial blood pressure (MAP), end-tidal carbon dioxide (EtCO₂), cerebral saturation (SctO₂), postanesthesia care unit (PACU) length of stay, and incidence of postoperative nausea and vomiting (PONV). RESULTS Thirty-one subjects were enrolled into the study. Univariate analyses showed cross-correlation between concurrent EtCO₂ values and SctO₂ of 0.43 (95% CI: 0.27 to 0.59) and between present EtCO₂ and the SctO₂ 5 minutes later of 0.46 (95% CI: 0.33 to 0.59). MAP was not significantly cross-correlated with SctO₂. Patients who had an SctO₂ below 60% at any time had a median (interquartile range [IQR]) PACU length of stay of 167 (IQR, 95-386) minutes. Patients whose cerebral saturation did not fall below 60% at any time had a median PACU length of stay of 103 (IQR, 76-155) minutes. This difference did not reach statistical significance (P = .257). The median (IQR) maximum decline in SctO₂ for patients with PONV was 11.2% (IQR, 8.2%-13.1%) and for patients without PONV was 7.1% (IQR, 5.1%-9.8%) (P = .126). CONCLUSIONS Cerebral oximetry monitoring was feasible during functional endoscopic sinus surgery. This study demonstrated a cross-correlation between EtCO₂ and SctO₂, but not MAP and SctO₂. A longer PACU length of stay and higher rate of PONV were seen but did not reach statistical significance.
Collapse
Affiliation(s)
- Joshua A Heller
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | | | | | | | | | | |
Collapse
|
49
|
Gan EC, Alsaleh S, Manji J, Habib ARR, Amanian A, Javer AR. Hemostatic effect of hot saline irrigation during functional endoscopic sinus surgery: a randomized controlled trial. Int Forum Allergy Rhinol 2014; 4:877-84. [PMID: 25137523 DOI: 10.1002/alr.21376] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 06/01/2014] [Accepted: 06/23/2014] [Indexed: 01/24/2023]
Abstract
BACKGROUND The endoscopically magnified operative field in functional endoscopic sinus surgery (FESS) makes even a small amount of bleeding a potentially significant hindrance. It is thought that irrigation with hot saline during surgery may improve surgical field of view by producing a hemostatic effect. Our objective was to assess the effectiveness of hot saline irrigation (HSI) compared to room temperature saline irrigation (RTSI) in the control of intraoperative bleeding during FESS. METHODS Sixty-two chronic rhinosinusitis (CRS) patients undergoing FESS were randomized to 2 treatment arms in an equal ratio. Subjects received either HSI (49°C) or RTSI (18°C), 20 mL every 10 minutes, for the duration of FESS. The Boezaart endoscopic field of view grading system was the primary outcome measure. Boezaart score, heart rate, and mean arterial blood pressure (MABP) were recorded at 10-minute intervals between irrigations. RESULTS Mean endoscopic surgical field of view (Boezaart score) did not significantly differ between the HSI and RTSI groups (1.5 ± 0.6 vs 1.3 ± 0.5; p = 0.23). However, when FESS was longer than 2 hours in duration, the Boezaart scores were significantly better in the HSI group (1.6 ± 0.6 vs 1.2 ± 0.4; p = 0.04). We found that blood loss per minute was significantly reduced (p = 0.02) in all cases in which HSI was used (2.3 ± 1.0) compared to RTSI (1.7 ± 1.1). Despite this, heart rate (p = 0.32) and MABP (p = 0.14) did not significantly differ between treatment groups. CONCLUSION HSI may be beneficial in improving surgical field of view in FESS after 2 hours of operating time. A significant reduction in rate of blood loss may be attained with HSI.
Collapse
Affiliation(s)
- Eng Cern Gan
- Division of Otolaryngology, University of British Columbia, St. Paul's Sinus Centre, Vancouver, British Columbia, Canada
| | | | | | | | | | | |
Collapse
|
50
|
Oxidised cellulose powder for haemostasis following sinus surgery: a pilot randomised trial. The Journal of Laryngology & Otology 2014; 128:709-13. [PMID: 25076139 DOI: 10.1017/s0022215114001303] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Haemorrhage is the most common major complication of endoscopic sinus surgery. Post-operative absorbable or non-absorbable nasal packing can cause pain and blockage. Haemostatic powders or gels may prevent this problem. However, when based on factors in the clotting cascade, they induce an inflammatory reaction and can cause post-operative synechiae. Oxidised cellulose powder produces haemostasis without inducing synechiae formation, but has not been trialled for sinus surgery. METHOD A randomised clinical trial was performed to compare cellulose powder to non-absorbable packing following sinus surgery. Participants were 50 consecutive patients undergoing sinus surgery, 47 of whom completed the study. The main outcome measures were post-operative bleeding, pain scores and synechiae formation. RESULTS Cellulose powder was effective at stopping bleeding, and was associated with less pain than nasal packing, with no evidence of increased synechiae formation. CONCLUSION Cellulose powder appears to be a good haemostatic agent following sinus surgery. A larger trial would allow more accurate quantification of its effectiveness.
Collapse
|