A comparison of cocaine vs. lidocaine with oxymetazoline for use in nasal procedures

Medical use of cocaine and perioperative morbidity following sinonasal surgery-A population study

Background

Topical cocaine is favoured by many surgeons for sinonasal surgery due to its superior vasoconstrictive and anesthetic properties. However, historical reports suggesting cocaine is associated with an increased risk of cardiac events have led many surgeons to turn to alternative topical medications. The objective of this study was to determine whether cocaine use during sinonasal surgery is associated with an increased risk of perioperative cardiac events and death.

Methods

We conducted a population-based analysis of patients undergoing sinonasal surgery from 2009–2016 using linked administrative health care data sets in Ontario, Canada. We compared patients treated at institutions that primarily use topical cocaine (exposed group) to those treated at institutions that do not use cocaine (unexposed group). Our primary outcome was a composite of major cardiac events or all-cause mortality within 48 hours of surgery. Due to low event rates, the outcome was compared using a Fisher’s exact test.

Results

Of 10,549 patients who were included in the study, 27.4% were treated at an institution that uses topical cocaine. The rate of the composite of perioperative major cardiac event or all-cause mortality within 48 hours of surgery in the exposed and unexposed groups was, ≤0.2% and 0 (p-value>0.05), respectively.

Conclusions

In this large real-world cohort of patients undergoing sinonasal surgery, there does not appear to be any significant increased risk of morbidity or mortality associated with cocaine use. These findings have important implications for surgeons performing this procedure.

Investigation of topical intranasal cocaine for sinonasal procedures: a randomized, phase III clinical trial

BACKGROUND

The objective of this trial was to demonstrate the clinical efficacy and safety of topical cocaine as part of the effort to gain regulatory approval from the United States Food and Drug Administration.

METHODS

This phase III, randomized, prospective, double-blind, multicenter, single-dose, placebo- and dose-controlled, parallel-group study aimed to evaluate the safety and efficacy of topical intranasal cocaine (RX0041-002). A total of 925 subjects were screened and a total of 648 subjects were randomized: 95 to placebo; 275 to 4% RX0041-002; and 278 to 8% RX0041-002. Efficacy was assessed with subjective pain intensity scores using the visual numeric rating scale and objectively using the von Frey filament test. Adverse events (AEs), vital signs, Holter monitoring, nasal irritation on visual examination, and smell assessment were recorded. The placebo and experimental groups were compared using a two-tailed Fisher's exact test.

RESULTS

Topical 4% and 8% cocaine achieved significant subject analgesia, the primary efficacy endpoint. Both doses were safe and well-tolerated, with a safety profile similar to placebo. In the 4% and 8% groups, headache (1.5% and 2.5%, respectively), epistaxis (0.7% and 1.1%), and anxiety (0.7% and 0%) were the only AEs reported by >1 subject. No cardiovascular AEs, serious AEs, or deaths occurred. A higher percentage of subjects in the 4% and 8% groups compared with the placebo group had a modest increase in either systolic or diastolic blood pressure.

CONCLUSION

Topical 4% and 8% cocaine is an effective anesthetic that can be safely administered for nasal procedures.

Awake Laryngoscopy in the Emergency Department

BACKGROUND

Many emergency physicians gain familiarity with the laryngeal anatomy only during the brief view achieved during rapid sequence induction and intubation. Awake laryngoscopy in the emergency department (ED) is an important and clinically underutilized procedure.

DISCUSSION

Providing benefit to the emergency physician through a slow, controlled, and deliberate examination of the airway, awake laryngoscopy facilitates confidence in the high-risk airway and eases the evolution to intubation, should it be required. Emergency physicians possess all the tools and skills required to effectively perform this procedure, through either the flexible endoscopic or rigid approaches. The procedure can be conducted utilizing local anesthesia with or without mild sedation, such that patients protect their airway.

CONCLUSION

We discuss two clinical scenarios, indications/contraindications, patient selection, and steps to performing two approaches to awake laryngoscopy in the ED.

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

BACKGROUND

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

OBJECTIVE OF REVIEW

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

TYPE OF REVIEW

Systematic review.

SEARCH STRATEGY

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

EVALUATION METHOD

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

RESULTS

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

CONCLUSION

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

[Comparison between topical anaesthesia with cocaine versus lidocaine plus adrenaline for outpatient laser dacryocystorhinostomy]

OBJECTIVE

To evaluate the effectiveness of topical anaesthesia with cocaine versus lidocaine plus adrenaline for outpatient transcanalicular and endonasal dacryocystorhinostomy (TCLDCR) with diode laser under sedation.

METHODS

A double blind randomised clinical trial was designed using topical anaesthesia for outpatient TCLDCR in the treatment of adult epiphora. A total of 92 patients were enrolled, and randomly allocated to be operated on under sedation and topical anaesthesia with cocaine 4% pledgets versus sedation and topical anaesthesia with lidocaine 2% plus 1/100.000 adrenaline pledgets. Main outcome measures were postoperative comfort, evaluated by a visual analogue scale, presence of secondary effects (blood pressure, heart rate), and resolution of epiphora, evaluated by Munk's scale and endoscopic control.

RESULTS

Patients in both groups reported being comfortable during and immediately after TCLDCR. Visualization of the operative field was adequate, and surgery was successfully completed in all cases. Complications were more common in the cocaine group: Sixteen patients from the cocaine group had high blood pressures, versus 2 patients from the lidocaine group (RR=8). Mean blood loss was 6.09 ml in cocaine group, versus 2.05 ml in lidocaine group (RR=6). Both parameters were statistically significant (p=1,1×10(-9)). There were no cases of postoperative epistaxis requiring nasal packing or hospital admission in any group. Success rate was similar in the 2 groups (86.96% group 1 and 89.13% group 2), after 6 months of follow-up.

CONCLUSIONS

The combination of topical lidocaine and adrenaline is more effective for outpatient transcanalicular and endonasal dacryocystorhinostomy than topical cocaine. Patient comfort was adequate in both groups, but high blood pressure and blood loss more common after cocaine.

Coronary spasm after the topical use of cocaine in nasal surgery

Background:

Cocaine is a frequently used recreational drug which imposes important health problems with even life-threatening cardiotoxicity. The therapeutic use of cocaine is nowadays restricted to topical anesthesia in ophthalmological and nasal surgery but the possible hazards of this local anesthesia are not always fully appreciated.

Case Report:

A 51-year old male patient with moderate cardiovascular risk profile underwent elective nasal surgery and cocaine was used as a local anesthetic. During surgery, ventricular arrhythmias and cardiogenic shock occurred, mimicking an ST-segment elevation myocardial infarction (STEMI) in sinus rhythm. Coronary angiography showed diffuse spasm of the right coronary artery (RCA) which disappeared with intracoronary nitrates. Urine analysis was positive for cocaine. The patient recovered completely with a normal echocardiography and ECG at discharge.

Conclusions:

Cocaine cardiotoxicity is not uncommon in the community but a particular situation arises when used in medicine as a topical anesthetic. This is the first case report, to our knowledge, of a cardiogenic shock mimicking a STEMI with documentation of diffuse coronary spasm after cocaine use in nasal surgery. One must be aware of the potential life-threatening complications in this low-risk surgery, moreover when safer alternatives are available.

A prospective, randomized, double-blind study comparing the efficacy of topical anesthetics in nasal endoscopy

INTRODUCTION

Transnasal endoscopy is commonly performed in an outpatient otolaryngology setting. Patients are typically administered a topical anesthetic and decongestant prior to this procedure to alleviate discomfort and improve visualization. There is no consensus on which topical anesthetic is most effective in optimizing patient experience during the procedure.

OBJECTIVE

To determine whether there is a difference in the efficacy between atomized 2% tetracaine and 4% lidocaine as a topical anesthetic prior to transnasal endoscopy.

STUDY DESIGN

Prospective, randomized, double-blind study.

METHODS

A total of 99 patients received oxymetazoline and were randomized to receive either 2% tetracaine or 4% lidocaine prior to transnasal endoscopy. Immediately following the procedure, participants completed a survey assessing level of discomfort and other adverse symptoms pertaining to the procedure using a 10-point visual analog scale (VAS).

RESULTS

There were no significant differences in VAS scores between the lidocaine and tetracaine groups. There were also no significant differences between genders in overall VAS scores and in the lidocaine and tetracaine subgroups. Older patients demonstrated significantly less discomfort or a sensation of bad taste overall. In contrast to patients receiving lidocaine, older patients receiving tetracaine experienced significantly less overall pain and discomfort, unpleasant taste, and dyspnea.

CONCLUSION

In patients undergoing transnasal endoscopy, use of either 2% tetracaine or 4% lidocaine has similar effect. Tetracaine may be a better choice in older patients, however.

Rhinoplasty

LEARNING OBJECTIVES

After reading this article, the participant should be able to: 1. Discuss desired preoperative aesthetic and functional assessment of the postsurgical nose with rhinoplasty patients. 2. Identify factors that have the potential to affect procedural outcomes. 3. Develop an operative plan to address aesthetic goals while preserving/improving nasal airway function. 4. Recognize and manage complications following rhinoplasty.

SUMMARY

Rhinoplasty is one of the most commonly performed aesthetic surgical procedures in plastic surgery. Over the past 20 years, the trend has shifted away from ablative techniques involving reduction or division of the osseocartilaginous framework to conserving native anatomy with cartilage-sparing suture techniques and augmentation of deficient areas to correct contour deformities and restore structural support. Accurate preoperative systematic nasal analysis and evaluation of the nasal airway, along with identification of both the patient's expectations and the surgeon's goals, form the foundation for success. Intraoperatively, adequate anatomical exposure of the nasal deformity; preservation and restoration of the normal anatomy; correction of the deformity using incremental control, maintenance, and restoration of the nasal airway; and recognition of the dynamic interplays among the composite of maneuvers are required. During postoperative recovery, care and reassurance combined with an ability to recognize and manage complications lead to successful outcomes following rhinoplasty.

Xylometazoline pretreatment reduces nasotracheal intubation-related epistaxis in paediatric dental surgery

BACKGROUND

Epistaxis is the most common complication encountered during nasotracheal intubation (NTI) in children. The aim of this study was to test the efficacy of prophylactic intranasal admixture of xylometazoline and local anaesthetic gel in reducing epistaxis after NTI in children.

METHODS

Children presenting for dental procedures requiring NTI were randomly allocated into two groups: Group 1 (xylometazoline group, n=53) and Group 2 (control group, n=51). After sevoflurane inhalation induction, the more patent nostril in each subject was lubricated with lidocaine 2% (1 ml) jelly, followed by 0.6 ml of either xylometazoline hydrochloride 0.1% nasal drops (Group 1) or sodium chloride 0.9% (Group 2). The presence and extent of bleeding occurring during intubation, extubation, or both and navigability through the nasal passage were assessed.

RESULTS

The incidence and severity of bleeding were significantly reduced between the study group (7.5%) compared with the control group (27.5%; P<0.01). Navigability was similar in both groups.

CONCLUSIONS

Admixture of intranasal xylometazoline 0.1% drops and lidocaine 2% jelly reduced the incidence and severity of epistaxis after NTI in preschool children.

Lidocaine spray vs tetracaine solution for transnasal fiber-optic laryngoscopy

STATEMENT OF PROBLEM

The aim of this study was to evaluate the efficacy of lidocaine spray 10%, compared with tetracaine 2% solution, as a local anesthetic for patients undergoing transnasal fiber-optic laryngoscopy.

METHOD OF STUDY

A prospective study was conducted on patients undergoing transnasal fiber-optic laryngoscopy. Microsurgical sponges were applied in each side of the nose for 10 minutes before laryngoscopy. Patients were randomly classified into group A and group B, in which tetracaine 2% solution and lidocaine spray 10% were used, respectively. Patients were asked to evaluate the severity of pain during the procedure by a visual analog scale. Patients data, pain score, and potential complications were placed in a database and statistically assessed.

MAIN RESULTS

Our series consisted of 48 patients. Statistical analysis showed significant lower mean nasal discomfort score in favor of the tetracaine group (2.29 vs 3.04 [P < .001]). No tetracaine complications or side effects occurred.

PRINCIPAL CONCLUSION

Neurosurgical sponge application of tetracaine 2% solution is an easy, safe, inexpensive, and effective analgesia for transnasal fiber-optic laryngoscopy.

Effectiveness of pre-emptive metoclopramide infusion in alleviating pain, discomfort and nausea associated with nasogastric tube insertion: a randomised, double-blind, placebo-controlled trial

Aim of this study was to demonstrate that intravenous metoclopramide can reduce pain, nausea and discomfort during nasogastric tube (NGT) insertion in ED. This prospective, randomised, double-blind, placebo-controlled trial was conducted in the university-based ED. One-hundred patients were enrolled. Before NGT insertion, each eligible patient was randomised to one of the two treatment arms: one group received 2 cc of 10 mg IV metoclopramide, whereas others received 2 cc of normal saline. Before and after the procedure, pain, nausea and discomfort were evaluated using 100-mm visual analogue scale (VAS). This study was analysed using the paired sample test, the independent sample test and the chi(2) test. Forty-nine patients received metoclopramide, and 51 received normal saline. Although initial VAS levels elicited for pain, nausea and discomfort were similar, consequent VAS levels of those in the metoclopramide group were significantly lower as compared with those in the normal saline group. The mean differences of VAS levels were statistically significant for three symptoms (p < 0.001). Mean VAS levels of nausea, discomfort and pain during NGT insertion were significantly lower following administration of IV metoclopramide as compared with normal saline.

Update on olfactory mucosal metabolic enzymes: age-related changes and N-acetyltransferase activities

We have expanded previous observations on olfactory metabolic enzymes by examining the content of various metabolic enzymes in the olfactory mucosa of the male Long-Evans rat at different ages. Age-related changes in metabolic enzyme content may be related to changes in susceptibility to toxicants with age and may also contribute to altered odorant perception in the elderly. While some enzymes did not vary over the age range examined, decreases in the microsomal content of other enzymes were observed. While mRNA for acetyltransferase enzymes has previously been described in olfactory mucosa, the markedly higher activity of olfactory acetyltransferases compared to liver had not previously been described. Acetyltransferases are important in the metabolism of drugs and toxicants that are aromatic amine derivatives and may contribute to the bioactivation of rodent olfactory mucosal carcinogens such as 2,6-dimethylaniline and alachlor. These studies show that the olfactory mucosa varies in its metabolic capacity with age, and characterize another class of metabolic enzymes in the olfactory mucosa, both of which may impact significantly on responses to toxicants and therapeutic agents in the nasal cavity.

What is the best topical anesthetic for nasogastric insertion? A comparison of lidocaine gel, lidocaine spray, and atomized cocaine

INTRODUCTION

Nasogastric intubation has been shown to be a painful procedure for patients. Previous studies have demonstrated the benefit of topical nasal anesthesia in decreasing the pain of this procedure. This study attempts to identify which of 3 topical anesthetic modalities would be preferred by patients.

METHODS

This study had a double-blind, double-dummy randomized triple crossover design with 30 healthy volunteers as participants. Each participant had 3 nasogastric tubes inserted and acted as his or her own control for the 3 study medications: 1.5 mL 4% atomized lidocaine, 1.5 mL 4% atomized cocaine, and 5 mL 2% lidocaine gel. Participants scored pain of tube passage through the nostril as well as global discomfort. They were also asked to identify which agent they preferred.

RESULTS

In our 30 subjects, although no statistically significant difference in nasal pain scores was found, "global discomfort" was less with the lidocaine gel (P =.017). Participants preferred the lidocaine gel over atomized cocaine (P <.00), but not to a statistically significant degree.

DISCUSSION

Two percent lidocaine gel appeared to provide the best option for a topical anesthetic during nasogastric tube insertion.

Midline Nasal and Hard Palate Destruction in Cocaine Abusers and Cocaine's Role in Rhinologic Practice

Intranasal cocaine abuse can lead to destruction of the palate and perforation of the nasal septum. The pathophysiology of cocaine-induced midline destructive lesions is multifactorial and includes local ischemia secondary to vasoconstriction, chemical irritation from adulterants put in “cut” cocaine, and infection secondary to trauma, impaired mucociliary transport, and decreased humoral and cell-mediated immunity. Cocaine abuse should be suspected in patients with a palatal or septal perforation of unknown etiology.

Comparison of oxymetazoline and lidocaine versus cocaine for outpatient dacryocystorhinostomy

PURPOSE

To evaluate the effectiveness of oxymetazoline combined with lidocaine versus cocaine for outpatient dacryocystorhinostomy (DCR).

METHODS

Twenty-seven patients underwent DCR with a combination of oxymetazoline 0.05% nasal spray and lidocaine 4% spray/pledgetts (oxy/lido) and were compared with 28 patients who underwent DCR with cocaine 4% pledgetts for nasal anesthesia and vasoconstriction. Most of the patients underwent standard external approach DCR: five patients in the oxy/lido group and four patients in the cocaine group underwent endoscopic DCR.

RESULTS

Patients in both groups reported being comfortable during and immediately after surgery. Visualization of the operative field was adequate, and surgery was successfully completed in all cases. Mean blood loss was 6.3 ml (+/-6.0) in the oxy/lido group and 7.3 ml (+/-6.4) in the cocaine group (p = 0.541). There were no cases of postoperative epistaxis requiring nasal packing or hospital admission in the oxy/lido group, whereas one patient in the cocaine group developed epistaxis 8 days after surgery, which required treatment. Success rate was similar in the two groups.

CONCLUSIONS

The combination of oxymetazoline and lidocaine is effective for outpatient dacryocystorhinostomy. Patient comfort was adequate and blood loss not significantly different in comparison to cocaine. This combination provides effective nasal anesthesia and vasoconstriction, while avoiding the "hassle" and potentially greater risks associated with cocaine.

Nasal nitric oxide is not altered by topical anesthesia

This prospective study was undertaken to determine whether topical nasal anesthetic agents affect nasal nitric oxide (NO) output in healthy adults. Seven volunteers (aged: 29-56 (40.6 +/- 10.7) years, six male), were recruited. A topical anesthetic (4% lidocaine or 0.5% tetracaine) was sprayed into the subject's right nostril while the left nostril served as a control. Unilateral nasal NO and nasal volume were measured before administration of the anesthetic and at 15 and 30 minutes after the administration. The mean (+/- SD) unilateral nasal NO output was 307 +/- 45.9 nL/minute from the right nostril (exposure side) before the topical application of lidocaine. At 30 minutes after topical application (n = 6), it was 295.5 +/- 41.5 in the right nostril and 297.5 +/- 39.8 in the left (control side). In the tetracaine group (n = 7), the mean (+/- SD) unilateral nasal NO output was 302 +/- 53.3 before the administration and 307 +/- 39.7 at 30 minutes after the administration in the right nostril. The mean NO output in the left nostril at 30 minutes after the administration was 297.7 +/- 40.75. In neither group was there any significant difference in nasal NO output between either the pre- and postlocal anesthetic application on the exposure side (Group 1, P = 0.76; group 2, P = 0.41) or the two nostrils after topical anesthesia application (group 1, P = 0.83; group 2, P = 0.62). Topical anesthesia with either lidocaine or tetracaine does not alter nasal NO output. NO measurement should not be affected in circumstances that require topical anesthesia of the nasal cavity.

Comparison of topical anesthetics and vasoconstrictors vs lubricants prior to nasogastric intubation: a randomized, controlled trial

OBJECTIVE

To determine whether pre-treatment of the nose and throat with topical anesthetics and vasoconstrictors would reduce the pain associated with nasogastric (NG) intubation.

METHODS

This was a prospective, randomized, controlled trial assessing the pain of NG intubation in patients pretreated with topical anesthetics and vasoconstrictors vs surgical lubricants alone. The subjects were 40 alert, cooperative adult patients requiring NG intubation without allergies to the study medications or contraindications to their use from a suburban university-based ED. The patients in the experimental group had phenylephrine 0.5% sprayed in their noses followed by instillation of 5 mL of 2% lidocaine jelly. Their throats were sprayed with 2% tetracaine and 14% benzocaine. The control patients received intranasal lubrication only. The primary outcome measured was pain of NG intubation on a 100-mm visual analog scale. Other outcomes included nasal pain, discomfort from gagging, and the incidences of vomiting, choking, and epistaxis.

RESULTS

The mean age (+/-SD) was 54.8+/-22.3 years; 20 (50%) were female. The patients who had a combination of topical anesthetics and vasoconstrictors inserted prior to NG intubation experienced significantly less overall pain/ discomfort than did the control patients [28.6 mm (95% CI = 17.3 to 39.9 mm) vs 57.5 mm (95% CI = 44.9 to 70.1 mm), p = 0.001]. The patients in the experimental group also experienced significantly less nasal pain than did the patients in the control group [18.1 mm (95% CI = 8.0 to 28.2 mm) vs 44.4 mm (95% CI = 30.4 to 58.6 mm), p = 0.003] and significantly less discomfort from gagging than the patients receiving pretreatment with a lubricant alone [24.1 mm (95% CI = 11.1 to 37.1 mm) vs 50.9 mm (95% CI = 36.7 to 65.1 mm), p = 0.006]. There was no between-group difference in the frequencies of adverse effects.

CONCLUSIONS

Use of topical lidocaine and phenylephrine for the nose and tetracaine with benzocaine spray for the throat prior to NG intubation results in significantly less pain and discomfort than use of a nasal surgical lubricant alone. Widespread use of topical anesthetics and vasoconstrictors prior to NG intubation is recommended.

Lignocaine with adrenaline: is it as effective as cocaine in rhinological practice?

This double-blind study compares the effectiveness of two local anaesthetics with vasoconstrictive activity (10% cocaine and 4% lignocaine with adrenaline 1:1000) used in the nose. Anterior rhinomanometry was used to assess changes in nasal mucosal blood volume from a reduction in congestion of the nasal mucosa with a resulting reduction in nasal resistance. Nasendoscopy was then performed and the degree of subjective discomfort evaluated. Twenty patients presenting with nasal obstruction but without evidence of structural disease and nine healthy volunteers were entered into the study. Each received 10% cocaine in one nostril, and 4% lignocaine with adrenaline (1:1000) in the other in a double-blind study. In all subjects, there was a significant reduction of nasal resistance after the administration of both drugs (P < 0.005). The anaesthetic effects of both agents were comparable with subjects reporting only a mild discomfort during nasendoscopy. We conclude from this study that 4% lignocaine with adrenaline (1:1000) solution is as effective as 10% cocaine.

Intranasal Anesthetic Effects of Lidocaine and Tetracaine Compared

The quality of nasal anesthesia obtained with two local anesthetic solutions (2% lidocaine in oxymetazoline and 1% tetracaine in oxymetazoline) was evaluated in this double-blind, randomized study. Each local anesthetic mixture was applied to the nasal septum of healthy volunteers with medication-soaked pledgets. Measurements of anesthetic effect (sensation threshold and pain perception) were made with Semmes-Weinstein monofilaments (North Coast Medical, San Jose, Calif.). Measurements were performed before local anesthetic application and at 10 and 70 minutes after local anesthetic application. Subjects had greater increases in sensation threshold with tetracaine than with lidocaine at both 10 and 70 minutes ( p = 0.0005 and p = 0.0001, respectively). Subjects had greater decreases in pain perception with tetracaine than with lidocaine at both time intervals ( p = 0.0003 and p < 0.0001, respectively). Tetracaine mixed with oxymetazoline appears to be a superior topical anesthetic for nasal procedures.

Cocaine, lidocaine, tetracaine: which is best for topical nasal anesthesia?

The quality of nasal anesthesia obtained with three local anesthetic solutions (4% cocaine, 2% lidocaine in oxymetazoline, and 1% tetracaine in oxymetazoline) was evaluated in a randomized study. Each local anesthetic mixture was applied to the nasal septum of healthy volunteers using medication-soaked pledgets. Measurements of anesthetic effect (sensation threshold and pain perception) were made with Semmes-Weinstein monofilaments. Measurements were performed prior to local anesthetic application and 10 and 70 min after local anesthetic application. Subjects had greater increases in sensation threshold with tetracaine than with lidocaine or cocaine at both 10 and 70 min (P < 0.05). Subjects had greater decreases in pain perception with tetracaine than with lidocaine or cocaine at both time intervals (P < 0.05). Tetracaine mixed with oxymetazoline appears to be a superior topical anesthetic for nasal procedures.

Effects of topical nasal decongestants on histology of nasal respiratory mucosa in rabbits

The aim of this study was to evaluate histologic changes after long-term administration of the topical nasal decongestants phenylephrine and oxymetazoline. Ninety healthy rabbits were divided into 3 groups for topical administration for 1 week, 2 weeks, and 4 weeks. Each group was subdivided into 3 subgroups by topical administration of phenylephrine. oxymetazoline, and physiologic saline as controls. Each study group thus consisted of 10 rabbits. Phenylephrine was administered by 2 puffs in the left nostril 5 times daily and oxymetazoline by 2 puffs twice a day using metered sprayers giving 0.10 ml in each puff with a dosage used in clinical practice. For statistical significance the Kolmogorov-Smirnov test was used. Light and electron microscopic examination were performed after obtaining nasal respiratory mucosa from the nasal septum of the rabbits. Administration of phenylephrine and oxymetazoline for more than 2 weeks caused histologic changes including ciliary loss, epithelial ulceration, inflammatory cell infiltration and subepithelial edema, and the changes were more pronounced with increasing administration duration of the decongestants. Ciliary loss was prominent in the 4-week phenylephrine and oxymetazoline groups. There were significantly severer changes in the morphologic variables in the decongestant groups compared with the control group according to administration duration (p < 0.05). Dilatation or vacuolization of mitochondria and endoplasmic reticula and vesicles ill the cytoplasm were observed in the 2- and 4-week phenylephrine groups as well as the 2- and 4-week oxymetazoline groups. Mild widening of the intercellular space was observed in the 4-week phenylephrine group. Purulent maxillary sinusitis developed in 6 of 10 rabbits treated for 4 weeks with phenylephrine. The results of this study suggest that the administration of decongestants may cause ciliary loss with subsequent inflammatory changes in the nasal respiratory mucosa.