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Effect of greater palatine canal injection on estimated blood loss during endoscopic sinus surgery
AMERI CAN JOURNAL OF OT OLA RYNGOLOGY–H E A D A N D N EC K ME D IC IN E AN D S U RG ER Y 35 ( 20 1 4 ) 1 –4
Available online at www.sciencedirect.com
ScienceDirect www.elsevier.com/locate/amjoto
Original contributions
Effect of greater palatine canal injection on estimated blood loss during endoscopic sinus surgery☆ Jean Anderson Eloy, MD, FACS a, b, c,⁎, Olga Kovalerchik, BA a , Michael Bublik, MD d , Jose W. Ruiz, MD d , Roy R. Casiano, MD d a
Department of Otolaryngology-Head & Neck Surgery, University of Medicine and Dentistry of New Jersey-New Jersey Medical School, Newark, NJ, USA b Department of Neurological Surgery, University of Medicine and Dentistry of New Jersey-New Jersey Medical School, Newark, NJ, USA c Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, University of Medicine and Dentistry of New Jersey-New Jersey Medical School, Newark, NJ, USA d Department of Otolaryngology, University of Miami Miller School of Medicine, 1475 NW 12th Avenue, Suite 4025, Miami, FL, USA
ARTI CLE I NFO
A BS TRACT
Article history:
Purpose: We compare estimated blood loss (EBL) during endoscopic sinus surgery (ESS)
Received 12 December 2012
between patients receiving transoral greater palatine canal (GPC) and transnasal infiltration (combined group) to patients receiving only transnasal infiltration (control group). CT stage, endoscopic stage, revision surgery, presence of polyps, degree of resident involvement, and operative time (OT) are also evaluated. Methods: Injection with 1% lidocaine with 1:100,000 epinephrine was performed through the GPC and transnasally in the “combined” study group (20 patients) and only transnasally in the control group (22 patients). Charts, operative reports, and CT scans were reviewed and demographic data as well as pertinent information collected. Data analysis was performed using SPSS Version 16 (SPSS Inc., Chicago, Illinois). Results: Twelve females and 8 males underwent combined injections and 16 males and 6 females received transnasal injections only. Average ratio of EBL to OT was 2.9 mL/min for the combined group and 4.1 mL/min for the control group (p = 0.05). Presence of polyps and revision surgery lead to a statistically significantly higher EBL (p < 0.05). Increased EBL and OT were noted with higher endoscopic and CT stages. No complications were reported. Conclusions: Increased endoscopic and CT stages, presence of polyps, and revision surgery may all lead to greater EBL in ESS. Although there was a trend towards decreased EBL in the combined group, this however did not reach statistical significance. Combined injection through the GPC and nasal cavity appears to be a safe method to decrease EBL during ESS. © 2014 Elsevier Inc. All rights reserved.
☆ Presented at the Annual Meeting of the American Academy of Otolaryngology-Head and Neck Surgery, Chicago, Illinois, September 21– 24, 2008. ⁎ Corresponding author. Department of Otolaryngology-Head and Neck Surgery, UMDNJ-New Jersey Medical School, 90 Bergen St., Suite 8100, Newark, NJ 07103, USA. Tel.: + 1 973 972 4588; fax: +1 973 972 3767. E-mail address: [email protected] (J.A. Eloy).
0196-0709/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjoto.2013.02.011
2
1.
AMERI CAN JOURNAL OF OT OLAR YNGOLOGY–H E A D A N D NE CK ME D IC IN E A ND S U RG ER Y 35 ( 20 1 4 ) 1 –4
Introduction
Endoscopic sinus surgery (ESS) is one of the most common surgical procedures performed by otolaryngologists. This minimally invasive technique is commonly used to restore sinus ventilation and function in patients with chronic sinusitis and nasal polyps for whom medical therapy has failed [1]. In the procedure, sinus air cells and sinus ostia are opened under direct visualization with the intent to restore normal mucociliary drainage. The main advantage of ESS as compared to conventional procedures is its less invasive nature, which results in less post-operative discomfort, provides better visualization, and thereby reduces complications [1,2]. The clinical outcomes after ESS are generally favorable, with success rates between 80% and 90% (i.e. majority of the patient's symptoms resolved) [3–6]. Endoscopic sinus surgery can be difficult because of the complex anatomy and proximity of vital structures such as the intracranial and intraorbital compartments. The presence of nasal polyps may also contribute to the challenges encountered in this area, as they obscure the visual field and have been associated with increased intraoperative blood loss. During ESS, the narrow confines of the surgical field can easily become obscured by small amounts of bleeding. Thus, in order to achieve optimal visualization, reduce complication, decrease operation time (OT), and improve outcomes, it is most beneficial to minimize bleeding during surgery. Traditionally, local anesthesia in ESS has consisted of one of the following: cotton-tip application of powdered cocaine (100–150 mg/side) to the nasal mucosa, transnasal injection of 1% lidocaine with 1:100,000 epinephrine, or transoral sphenopalatine block via the greater palatine canal (GPC) [7]. In addition to their anesthetic effects, these methods can help to decrease bleeding in the operative field by causing hemostasis through a variety of mechanisms, including epinephrineinduced vasoconstriction, mechanical tamponade of the vessels, and a parasympathetic block allowing unopposed sympathetic activity [8]. The modern technique for GPC injection, where the needle is bent at a 45° angle and advanced 25 to 28 mm once inside the foramen, was described in 1988 by Stankiewicz [9]. This was later reaffirmed by Douglass and Wormald in 2006 [10]. To date, only one study has been published that evaluates the role of GPC injection in ESS. Wormald et al. have shown that transoral injection of the GPC with 2% lidocaine and 1:80,000 epinephrine improves visualization during ESS [11]. The effects of GPC injection on quantitative blood loss in ESS, however, have yet to be described. In our study, we compare the estimated blood loss (EBL) during ESS between patients receiving transoral GPC and transnasal (TN) infiltration (combined) to patients receiving only TN infiltration.
2.
Patients and methods
After obtaining approval from the Institutional Review Board of the University of Miami (Miami, Florida), a retrospectively chart review was conducted of all patients who underwent ESS by the senior author (RRC) at the University of Miami
Hospital from September 1, 2007 to December 31, 2007. All patients undergoing ESS at this institution by the senior author during this time period were included in this analysis. Forty-two consecutive patients were identified. Twenty-two patients received transoral GPC and TN injections (combined group) with 1% lidocaine with 1:100,000 epinephrine. Two milliliters of 1% lidocaine with 1:100,000 epinephrine was injected transorally into the GPC on each side using a 25-gauge needle with a 45° bend 20–25 mm from the needle hub. The remaining 20 patients received only TN injection with 1% lidocaine with 1:100,000 epinephrine (control group). The decision for placement into the combined group was based on whether or not a rhinology fellow (JAE) was present to provide supervision of the injection. Intranasal injections were made at the superoanterior aspect of the middle turbinate and the uncinate process. The areas of the sphenopalatine region and tail of middle turbinate were injected when accessible. Nasal polyps were also directly injected if present. Records were evaluated for patient age, sex, diagnosis, operative procedure, OT, EBL, previous ESS, and perioperative as well as postoperative complications. The University of Miami CT staging system (which is similar to the Lund– MacKay CT scoring system) was used preoperatively to evaluate extent of sinonasal disease on CT scans. In addition, each patient's endoscopic exam was graded according to the University of Miami Chronic Rhinosinusitis Staging System (UMCRSS) [12]. All patients in this study failed medical management prior to surgery (including oral antibiotics as well as oral and topical corticosteroids). The main outcome measure was EBL. Other variables included: how EBL is affected by the duration of resident involvement, endoscopic stage, CT stage, presence of polyps, previous ESS, and OT. Statistical analysis was performed using SPSS version 16 (SPSS Inc., Chicago, IL). One way ANOVA (Chi-Square Tests) and Factorial ANOVA were used to analyze data. All tests were two-tailed and significance level was set at p < 0.05.
3.
Results
Twelve females and 8 males (average age of 48.3 years), underwent combined injections and 16 males and 6 females (average age 50.5 years old) received only TN injections (control group). Table 1 shows that the University of Miami CT staging score was not statistically different between the
Table 1 – Perioperative data comparison. Parameter Age (years) U Miami CT score OT (min) EBL (mL) Avr EBL/min
Combined Mean ± STD 48.3 13.3 110.7 346.5 2.9
± ± ± ± ±
15.2 7.1 55.2 267.0 1.5
Control Mean ± STD 50.5 14.8 109.9 492.9 4.1
± ± ± ± ±
15.0 6.1 50.5 424.5 2.3
P Value P P P P P
= = = = =
0.640 0.445 0.959 0.194 0.05
GP, greater palatine; TN, transnasal; STD, standard deviation; OT, operating time; Avr, average; EBL, estimated blood loss; (all P values were performed using Student's t-test, one-way ANOVA).
AMERI CAN JOURNAL OF OT OLA RYNGOLOGY–H E A D A N D N EC K ME D IC IN E AN D S U RG ER Y 35 ( 20 1 4 ) 1 –4
Table 2 – Effect of polpys on EBL during ESS. Parameter
Polyps EBL Mean ± STD
No Polyps EBL Mean ± STD
P Value
EBL 526.7 ± 381.1 (n = 29) 192.3 ± 156.6 (n = 13) P = 0.004* Avr EBL/min 4.0 ± 1.98 (n = 29) 2.5 ± 1.7 (n = 13) P = 0.02* STD, standard deviation; EBL, estimated blood loss; Avr, average;*, indicates significance; (all P values were calculated using one-way ANOVA).
combined injection group (mean of 13.3) and the control group (mean = 14.8, p = 0.445). The OT was not statistically different between the two groups (mean for combined of 110 min vs. 109 min for the control group, p = 0.959). Although not statistically significant (p = 0.194), there was a large difference in mean EBL between the groups (combined group was 346.5 mL; control group was 492.9 mL). The average EBL/min was lower in the combined injection group and trended toward, but did not reach, statistical significance (p = 0.05). Table 2 demonstrates the effect of polyps on EBL and average EBL/min. Patients with polyposis had statistically significant higher EBL (526.7 mL) when compared to patients without polyps (192.3 mL, p = 0.004). Similarly, average EBL/ min was statistically lower if the patients did not have polyps prior to surgery (p = 0.02). Patient who underwent revision surgery had a statistically significant greater EBL compared to patients undergoing intial ESS (p < .001). Non-revision cases had an average of 238.9 mL of EBL, while revision cases had an average of 668.9 mL of EBL (Table 3). Average EBL/min was lower in non-revision cases (2.5 mL/min vs. 4.9 mL/min, p < 0.001). Table 4 analyzes the effect of resident involvement on EBL and EBL/min. EBL and average EBL/min were not statistically significantly greater (p = .083 and p = 0.27, respectively) whether or not a resident performed greater than 50% of the case. Each patient's endoscopic exam was graded according to the UMCRSS and evaluated for EBL, EBL/min, and OT. Factorial ANOVA analysis (Table 5) showed that with increased endoscopic stage there were statistically significant increases in EBL and OT (p = 0.004 and p < 0.001, respectively). No such increase was observed in analysis of EBL/min (p = 0.079). No statistical significance was found between the combined and control groups within each endoscopic stage for EBL, EBL/min, and OT (p = 0.280, p = 0.061, and p = 0.349, respectively). Table 6 compares CT stage and demonstrates that as CT stage increases (for both the combined and control groups), the EBL, EBL/min, and OT values increase at statistically
Table 4 – Effect of EBL with resident performing greater than or less than 50% of the case. Parameter
Resident > 50% EBL Mean ± STD
Resident < 50% P Value EBL Mean ± STD
EBL 458.8 ± 370.4 (n = 37) 160.0 ± 89.4 (n = 5) P = 0.083 Avr EBL/min 3.7 ± 2.0 (n = 37) 2.6 ± 1.9 (n = 5) P = 0.27 STD, standard deviation; EBL, estimated blood loss; Avr, average; (all P values were calculated using one-way ANOVA).
significant amounts (p = 0.002, p = 0.021, and p = 0.001, respectively). However, the p-value did not reach statistical significance between the combined and control groups within each stage when compared for EBL, EBL/min, and OT (p = 0.232, p = 0.060, and p = 0.734, respectively).
4.
Discussion
Control of bleeding during ESS is important for visualization in order to avoid complications such as intraorbital or intracranial penetration. Hemostasis is also critical in patients who cannot afford a large amount of blood loss. Therefore, knowledge of the nasal vasculature and adequate injection techniques are important for appropriate hemostasis. Through the years, many techniques have been used to decrease intraoperative blood loss and improve visualization of the surgical field. Chemical treatments such as preoperative nasal decongestant with oxymetazoline hydrochloride, cocaine, and phenylephrine hydrochloride have all been used with varying degrees of success [13]. Hypotensive anesthesia, which might be achieved by agents such as sodium nitroprusside and esmolol, has also been advocated as a means of controlling intraoperative blood loss [14–16]. Use of coblationassisted nasal polypectomy has also been used with the intention of decreasing blood loss in ESS [17]. Here, we suggest the incorporation of an additional technique to be used during ESS that may safely contribute to reduction in EBL.
Table 5 – Effect of endoscopic stage on surgical blood loss and operative time. Parameter Endostage — Study Group
EBL Avr EBL/min OT Mean ± STD Mean ± STD Mean ± STD 212.2 ± 187.5 221.4 ± 239.5 275.0 ± 160.5 495.6 ± 378.6 674.0 ± 232.1 761.4 ± 485.8 P = 0.004*
2.8 ± 1.7 2.9 ± 2.33 2.1 ± 1.0 4.3 ± 2.4 3.9 ± 1.0 5.0 ± 1.8 P = 0.079
65.1 ± 28.3 75.1 ± 32.3 129.3 ± 45.8 109.9 ± 38.4 170.4 ± 24.2 144.6 ± 57.9 P < 0.001*
P = 0.280
P = 0.061
P = 0.349
EBL 668.9 ± 385.7 (n = 18) 238.9 ± 201.6 (n = 24) P < 0.001* Avr EBL/min 4.9 ± 1.8 (n = 18) 2.5 ± 1.5 (n = 24) P < 0.001*
1 — Combined 1 — Control 2 — Combined 2 — Control 3 — Combined 3 — Control P-value for increasing endostage P-value for difference between study groups
STD, standard deviation; EBL, estimated blood loss; Avr, average;*, indicates significance; (all P values were calculated using one-way ANOVA).
GP, greater palatine; TN, transnasal; STD, standard deviation; OT, operating time; Avr, average; EBL, estimated blood loss; *, indicates significance; (all P values were performed using Factorial ANOVA).
Table 3 – Effect of revision surgery on EBL during ESS. Parameter
Revision EBL Mean ± STD
Non Revision EBL P Value Mean ± STD
3
4
AMERI CAN JOURNAL OF OT OLAR YNGOLOGY–H E A D A N D NE CK ME D IC IN E A ND S U RG ER Y 35 ( 20 1 4 ) 1 –4
Table 6 – Effect of ct stage on surgical blood loss and operative time.
Acknowledgment
Parameter CT Stage — Study Group
EBL Avr EBL/min OT Mean ± STD Mean ± STD Mean ± STD
The authors would like to acknowledge Glen O. Allen, MPH for his assistance in the statistical analysis of the data.
1 — Combined 1 — Control 2 — Combined 2 — Control 3 — Combined 3 — Control p-value for increasing endostage p-value for difference between study groups
156.7 ± 121.9 232.1 ± 240.1 274.4 ± 179.2 486.3 ± 385.7 704.0 ± 174.2 761.4 ± 485.9 P = 0.002*
2.2 ± 1.1 2.6 ± 1.9 2.7 ± 1.7 4.6 ± 2.4 4.0 ± 0.6 5.0 ± 1.8 P = 0.021*
65.1 ± 28.3 82.7 ± 26.7 106.8 ± 51.1 103.3 ± 46.6 172.4 ± 21.3 144.6 ± 57.9 P = 0.001*
P = 0.232
P = 0.060
P = 0.734
GP, greater palatine; TN, transnasal; STD, standard deviation; OT, operating time; Avr, average; EBL, estimated blood loss; *, indicates significance; (all P values were performed using Factorial ANOVA).
Our findings solidify the preconceived notion that polyps and prior ESS significantly increase blood loss during ESS [18]. We found a statistically significant increase in EBL in patients with polyposis as well as in revision cases. Overall, the combined injection group benefited from a significantly lower EBL/min than the control group, and trended toward an overall reduced EBL. As endoscopic stage increased, there were statistically significant increases in EBL and OT. However, within each endoscopic stage, statistical significance was not reached. In addition, we found that as CT stage increased (both for the combined and control group), the EBL, EBL/min, and OT had statistically significant increases. Although we found an overall advantage in performing combined GPC and TN injections during ESS, there are several limitations to this study that need to be acknowledged. This study is subject to all the limitations inherent to a retrospective chart review and should be viewed in this context. Additionally, potential selection bias as well as small sample size may have confounded these results. Consequently, these early and promising findings would benefit from validation in the form of prospective randomized double blind studies. Nevertheless, we believe that these results can lay the framework for future investigations.
5.
Conclusion
Our results demonstrate that during ESS the addition of GPC injection to the traditional TN approach trends toward a decrease in overall EBL without reaching statistical significance. This technique appears to be a safe and relatively simple method that may potentially decrease EBL during ESS. We also learned that increased endoscopic and CT stages, presence of polyps, and revision surgery may all significantly lead to greater EBL.
REFERENCES
[1] Slack R, Bates G. Functional endoscopic sinus surgery. Am Fam Physician 1998;58:707–18. [2] Smith TL, Kern R, Palmer JN, et al. Medical therapy vs surgery for chronic rhinosinusitis: a prospective, multi-institutional study with 1-year follow-up. International Forum of Allergy & Rhinology 2012. [3] Stammberger H, Posawetz W. Functional endoscopic sinus surgery. Concept, indications and results of the Messerklinger technique. European archives of oto-rhino-laryngology: official journal of the European Federation of Oto-RhinoLaryngological Societies 1990;247:63–76. [4] Levine HL. Functional endoscopic sinus surgery: evaluation, surgery, and follow-up of 250 patients. Laryngoscope 1990;100:79–84. [5] Lund VJ, MacKay IS. Outcome assessment of endoscopic sinus surgery. J R Soc Med 1994;87:70–2. [6] Lund VJ, Scadding GK. Objective assessment of endoscopic sinus surgery in the management of chronic rhinosinusitis: an update. J Laryngol Otol 1994;108:749–53. [7] Thaler ER, Gottschalk A, Samaranayake R, et al. Anesthesia in endoscopic sinus surgery. Am J Rhinol 1997;11:409–13. [8] Das S, Kim D, Cannon TY, et al. High-resolution computed tomography analysis of the greater palatine canal. Am J Rhinol 2006;20:603–8. [9] Stankiewicz JA. Greater palatine foramen injection made easy. Laryngoscope 1988;98:580–1. [10] Douglas R, Wormald PJ. Pterygopalatine fossa infiltration through the greater palatine foramen: where to bend the needle. Laryngoscope 2006;116:1255–7. [11] Wormald PJ, Athanasiadis T, Rees G, et al. An evaluation of effect of pterygopalatine fossa injection with local anesthetic and adrenalin in the control of nasal bleeding during endoscopic sinus surgery. Am J Rhinol 2005;19:288–92. [12] Lehman DA, Casiano RR, Polak M. Reliability of the University of Miami chronic rhinosinusitis staging system. Am J Rhinol 2006;20:11–9. [13] Riegle EV, Gunter JB, Lusk RP, et al. Comparison of vasoconstrictors for functional endoscopic sinus surgery in children. Laryngoscope 1992;102:820–3. [14] Boezaart AP, van der Merwe J, Coetzee A. Comparison of sodium nitroprusside- and esmolol-induced controlled hypotension for functional endoscopic sinus surgery. Can J Anaesth 1995;42:373–6. [15] Saitoh K, Suzuki H, Hiruta A, et al. Induced hypotension for endoscopic sinus surgery. Masui 2002;51:1100–3. [16] Eberhart LH, Folz BJ, Wulf H, et al. Intravenous anesthesia provides optimal surgical conditions during microscopic and endoscopic sinus surgery. Laryngoscope 2003;113:1369–73. [17] Eloy JA, Walker TJ, Casiano RR, et al. Effect of coblation polypectomy on estimated blood loss in endoscopic sinus surgery. Am J Rhinol Allergy 2009;23:535–9. [18] Laguna D, Lopez-Cortijo C, Millan I, et al. Blood loss in endoscopic sinus surgery: assessment of variables. J Otolaryngol Head Neck Surg 2008;37:324–30.
Available online at www.sciencedirect.com
ScienceDirect www.elsevier.com/locate/amjoto
Original contributions
Effect of greater palatine canal injection on estimated blood loss during endoscopic sinus surgery☆ Jean Anderson Eloy, MD, FACS a, b, c,⁎, Olga Kovalerchik, BA a , Michael Bublik, MD d , Jose W. Ruiz, MD d , Roy R. Casiano, MD d a
Department of Otolaryngology-Head & Neck Surgery, University of Medicine and Dentistry of New Jersey-New Jersey Medical School, Newark, NJ, USA b Department of Neurological Surgery, University of Medicine and Dentistry of New Jersey-New Jersey Medical School, Newark, NJ, USA c Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, University of Medicine and Dentistry of New Jersey-New Jersey Medical School, Newark, NJ, USA d Department of Otolaryngology, University of Miami Miller School of Medicine, 1475 NW 12th Avenue, Suite 4025, Miami, FL, USA
ARTI CLE I NFO
A BS TRACT
Article history:
Purpose: We compare estimated blood loss (EBL) during endoscopic sinus surgery (ESS)
Received 12 December 2012
between patients receiving transoral greater palatine canal (GPC) and transnasal infiltration (combined group) to patients receiving only transnasal infiltration (control group). CT stage, endoscopic stage, revision surgery, presence of polyps, degree of resident involvement, and operative time (OT) are also evaluated. Methods: Injection with 1% lidocaine with 1:100,000 epinephrine was performed through the GPC and transnasally in the “combined” study group (20 patients) and only transnasally in the control group (22 patients). Charts, operative reports, and CT scans were reviewed and demographic data as well as pertinent information collected. Data analysis was performed using SPSS Version 16 (SPSS Inc., Chicago, Illinois). Results: Twelve females and 8 males underwent combined injections and 16 males and 6 females received transnasal injections only. Average ratio of EBL to OT was 2.9 mL/min for the combined group and 4.1 mL/min for the control group (p = 0.05). Presence of polyps and revision surgery lead to a statistically significantly higher EBL (p < 0.05). Increased EBL and OT were noted with higher endoscopic and CT stages. No complications were reported. Conclusions: Increased endoscopic and CT stages, presence of polyps, and revision surgery may all lead to greater EBL in ESS. Although there was a trend towards decreased EBL in the combined group, this however did not reach statistical significance. Combined injection through the GPC and nasal cavity appears to be a safe method to decrease EBL during ESS. © 2014 Elsevier Inc. All rights reserved.
☆ Presented at the Annual Meeting of the American Academy of Otolaryngology-Head and Neck Surgery, Chicago, Illinois, September 21– 24, 2008. ⁎ Corresponding author. Department of Otolaryngology-Head and Neck Surgery, UMDNJ-New Jersey Medical School, 90 Bergen St., Suite 8100, Newark, NJ 07103, USA. Tel.: + 1 973 972 4588; fax: +1 973 972 3767. E-mail address: [email protected] (J.A. Eloy).
0196-0709/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjoto.2013.02.011
2
1.
AMERI CAN JOURNAL OF OT OLAR YNGOLOGY–H E A D A N D NE CK ME D IC IN E A ND S U RG ER Y 35 ( 20 1 4 ) 1 –4
Introduction
Endoscopic sinus surgery (ESS) is one of the most common surgical procedures performed by otolaryngologists. This minimally invasive technique is commonly used to restore sinus ventilation and function in patients with chronic sinusitis and nasal polyps for whom medical therapy has failed [1]. In the procedure, sinus air cells and sinus ostia are opened under direct visualization with the intent to restore normal mucociliary drainage. The main advantage of ESS as compared to conventional procedures is its less invasive nature, which results in less post-operative discomfort, provides better visualization, and thereby reduces complications [1,2]. The clinical outcomes after ESS are generally favorable, with success rates between 80% and 90% (i.e. majority of the patient's symptoms resolved) [3–6]. Endoscopic sinus surgery can be difficult because of the complex anatomy and proximity of vital structures such as the intracranial and intraorbital compartments. The presence of nasal polyps may also contribute to the challenges encountered in this area, as they obscure the visual field and have been associated with increased intraoperative blood loss. During ESS, the narrow confines of the surgical field can easily become obscured by small amounts of bleeding. Thus, in order to achieve optimal visualization, reduce complication, decrease operation time (OT), and improve outcomes, it is most beneficial to minimize bleeding during surgery. Traditionally, local anesthesia in ESS has consisted of one of the following: cotton-tip application of powdered cocaine (100–150 mg/side) to the nasal mucosa, transnasal injection of 1% lidocaine with 1:100,000 epinephrine, or transoral sphenopalatine block via the greater palatine canal (GPC) [7]. In addition to their anesthetic effects, these methods can help to decrease bleeding in the operative field by causing hemostasis through a variety of mechanisms, including epinephrineinduced vasoconstriction, mechanical tamponade of the vessels, and a parasympathetic block allowing unopposed sympathetic activity [8]. The modern technique for GPC injection, where the needle is bent at a 45° angle and advanced 25 to 28 mm once inside the foramen, was described in 1988 by Stankiewicz [9]. This was later reaffirmed by Douglass and Wormald in 2006 [10]. To date, only one study has been published that evaluates the role of GPC injection in ESS. Wormald et al. have shown that transoral injection of the GPC with 2% lidocaine and 1:80,000 epinephrine improves visualization during ESS [11]. The effects of GPC injection on quantitative blood loss in ESS, however, have yet to be described. In our study, we compare the estimated blood loss (EBL) during ESS between patients receiving transoral GPC and transnasal (TN) infiltration (combined) to patients receiving only TN infiltration.
2.
Patients and methods
After obtaining approval from the Institutional Review Board of the University of Miami (Miami, Florida), a retrospectively chart review was conducted of all patients who underwent ESS by the senior author (RRC) at the University of Miami
Hospital from September 1, 2007 to December 31, 2007. All patients undergoing ESS at this institution by the senior author during this time period were included in this analysis. Forty-two consecutive patients were identified. Twenty-two patients received transoral GPC and TN injections (combined group) with 1% lidocaine with 1:100,000 epinephrine. Two milliliters of 1% lidocaine with 1:100,000 epinephrine was injected transorally into the GPC on each side using a 25-gauge needle with a 45° bend 20–25 mm from the needle hub. The remaining 20 patients received only TN injection with 1% lidocaine with 1:100,000 epinephrine (control group). The decision for placement into the combined group was based on whether or not a rhinology fellow (JAE) was present to provide supervision of the injection. Intranasal injections were made at the superoanterior aspect of the middle turbinate and the uncinate process. The areas of the sphenopalatine region and tail of middle turbinate were injected when accessible. Nasal polyps were also directly injected if present. Records were evaluated for patient age, sex, diagnosis, operative procedure, OT, EBL, previous ESS, and perioperative as well as postoperative complications. The University of Miami CT staging system (which is similar to the Lund– MacKay CT scoring system) was used preoperatively to evaluate extent of sinonasal disease on CT scans. In addition, each patient's endoscopic exam was graded according to the University of Miami Chronic Rhinosinusitis Staging System (UMCRSS) [12]. All patients in this study failed medical management prior to surgery (including oral antibiotics as well as oral and topical corticosteroids). The main outcome measure was EBL. Other variables included: how EBL is affected by the duration of resident involvement, endoscopic stage, CT stage, presence of polyps, previous ESS, and OT. Statistical analysis was performed using SPSS version 16 (SPSS Inc., Chicago, IL). One way ANOVA (Chi-Square Tests) and Factorial ANOVA were used to analyze data. All tests were two-tailed and significance level was set at p < 0.05.
3.
Results
Twelve females and 8 males (average age of 48.3 years), underwent combined injections and 16 males and 6 females (average age 50.5 years old) received only TN injections (control group). Table 1 shows that the University of Miami CT staging score was not statistically different between the
Table 1 – Perioperative data comparison. Parameter Age (years) U Miami CT score OT (min) EBL (mL) Avr EBL/min
Combined Mean ± STD 48.3 13.3 110.7 346.5 2.9
± ± ± ± ±
15.2 7.1 55.2 267.0 1.5
Control Mean ± STD 50.5 14.8 109.9 492.9 4.1
± ± ± ± ±
15.0 6.1 50.5 424.5 2.3
P Value P P P P P
= = = = =
0.640 0.445 0.959 0.194 0.05
GP, greater palatine; TN, transnasal; STD, standard deviation; OT, operating time; Avr, average; EBL, estimated blood loss; (all P values were performed using Student's t-test, one-way ANOVA).
AMERI CAN JOURNAL OF OT OLA RYNGOLOGY–H E A D A N D N EC K ME D IC IN E AN D S U RG ER Y 35 ( 20 1 4 ) 1 –4
Table 2 – Effect of polpys on EBL during ESS. Parameter
Polyps EBL Mean ± STD
No Polyps EBL Mean ± STD
P Value
EBL 526.7 ± 381.1 (n = 29) 192.3 ± 156.6 (n = 13) P = 0.004* Avr EBL/min 4.0 ± 1.98 (n = 29) 2.5 ± 1.7 (n = 13) P = 0.02* STD, standard deviation; EBL, estimated blood loss; Avr, average;*, indicates significance; (all P values were calculated using one-way ANOVA).
combined injection group (mean of 13.3) and the control group (mean = 14.8, p = 0.445). The OT was not statistically different between the two groups (mean for combined of 110 min vs. 109 min for the control group, p = 0.959). Although not statistically significant (p = 0.194), there was a large difference in mean EBL between the groups (combined group was 346.5 mL; control group was 492.9 mL). The average EBL/min was lower in the combined injection group and trended toward, but did not reach, statistical significance (p = 0.05). Table 2 demonstrates the effect of polyps on EBL and average EBL/min. Patients with polyposis had statistically significant higher EBL (526.7 mL) when compared to patients without polyps (192.3 mL, p = 0.004). Similarly, average EBL/ min was statistically lower if the patients did not have polyps prior to surgery (p = 0.02). Patient who underwent revision surgery had a statistically significant greater EBL compared to patients undergoing intial ESS (p < .001). Non-revision cases had an average of 238.9 mL of EBL, while revision cases had an average of 668.9 mL of EBL (Table 3). Average EBL/min was lower in non-revision cases (2.5 mL/min vs. 4.9 mL/min, p < 0.001). Table 4 analyzes the effect of resident involvement on EBL and EBL/min. EBL and average EBL/min were not statistically significantly greater (p = .083 and p = 0.27, respectively) whether or not a resident performed greater than 50% of the case. Each patient's endoscopic exam was graded according to the UMCRSS and evaluated for EBL, EBL/min, and OT. Factorial ANOVA analysis (Table 5) showed that with increased endoscopic stage there were statistically significant increases in EBL and OT (p = 0.004 and p < 0.001, respectively). No such increase was observed in analysis of EBL/min (p = 0.079). No statistical significance was found between the combined and control groups within each endoscopic stage for EBL, EBL/min, and OT (p = 0.280, p = 0.061, and p = 0.349, respectively). Table 6 compares CT stage and demonstrates that as CT stage increases (for both the combined and control groups), the EBL, EBL/min, and OT values increase at statistically
Table 4 – Effect of EBL with resident performing greater than or less than 50% of the case. Parameter
Resident > 50% EBL Mean ± STD
Resident < 50% P Value EBL Mean ± STD
EBL 458.8 ± 370.4 (n = 37) 160.0 ± 89.4 (n = 5) P = 0.083 Avr EBL/min 3.7 ± 2.0 (n = 37) 2.6 ± 1.9 (n = 5) P = 0.27 STD, standard deviation; EBL, estimated blood loss; Avr, average; (all P values were calculated using one-way ANOVA).
significant amounts (p = 0.002, p = 0.021, and p = 0.001, respectively). However, the p-value did not reach statistical significance between the combined and control groups within each stage when compared for EBL, EBL/min, and OT (p = 0.232, p = 0.060, and p = 0.734, respectively).
4.
Discussion
Control of bleeding during ESS is important for visualization in order to avoid complications such as intraorbital or intracranial penetration. Hemostasis is also critical in patients who cannot afford a large amount of blood loss. Therefore, knowledge of the nasal vasculature and adequate injection techniques are important for appropriate hemostasis. Through the years, many techniques have been used to decrease intraoperative blood loss and improve visualization of the surgical field. Chemical treatments such as preoperative nasal decongestant with oxymetazoline hydrochloride, cocaine, and phenylephrine hydrochloride have all been used with varying degrees of success [13]. Hypotensive anesthesia, which might be achieved by agents such as sodium nitroprusside and esmolol, has also been advocated as a means of controlling intraoperative blood loss [14–16]. Use of coblationassisted nasal polypectomy has also been used with the intention of decreasing blood loss in ESS [17]. Here, we suggest the incorporation of an additional technique to be used during ESS that may safely contribute to reduction in EBL.
Table 5 – Effect of endoscopic stage on surgical blood loss and operative time. Parameter Endostage — Study Group
EBL Avr EBL/min OT Mean ± STD Mean ± STD Mean ± STD 212.2 ± 187.5 221.4 ± 239.5 275.0 ± 160.5 495.6 ± 378.6 674.0 ± 232.1 761.4 ± 485.8 P = 0.004*
2.8 ± 1.7 2.9 ± 2.33 2.1 ± 1.0 4.3 ± 2.4 3.9 ± 1.0 5.0 ± 1.8 P = 0.079
65.1 ± 28.3 75.1 ± 32.3 129.3 ± 45.8 109.9 ± 38.4 170.4 ± 24.2 144.6 ± 57.9 P < 0.001*
P = 0.280
P = 0.061
P = 0.349
EBL 668.9 ± 385.7 (n = 18) 238.9 ± 201.6 (n = 24) P < 0.001* Avr EBL/min 4.9 ± 1.8 (n = 18) 2.5 ± 1.5 (n = 24) P < 0.001*
1 — Combined 1 — Control 2 — Combined 2 — Control 3 — Combined 3 — Control P-value for increasing endostage P-value for difference between study groups
STD, standard deviation; EBL, estimated blood loss; Avr, average;*, indicates significance; (all P values were calculated using one-way ANOVA).
GP, greater palatine; TN, transnasal; STD, standard deviation; OT, operating time; Avr, average; EBL, estimated blood loss; *, indicates significance; (all P values were performed using Factorial ANOVA).
Table 3 – Effect of revision surgery on EBL during ESS. Parameter
Revision EBL Mean ± STD
Non Revision EBL P Value Mean ± STD
3
4
AMERI CAN JOURNAL OF OT OLAR YNGOLOGY–H E A D A N D NE CK ME D IC IN E A ND S U RG ER Y 35 ( 20 1 4 ) 1 –4
Table 6 – Effect of ct stage on surgical blood loss and operative time.
Acknowledgment
Parameter CT Stage — Study Group
EBL Avr EBL/min OT Mean ± STD Mean ± STD Mean ± STD
The authors would like to acknowledge Glen O. Allen, MPH for his assistance in the statistical analysis of the data.
1 — Combined 1 — Control 2 — Combined 2 — Control 3 — Combined 3 — Control p-value for increasing endostage p-value for difference between study groups
156.7 ± 121.9 232.1 ± 240.1 274.4 ± 179.2 486.3 ± 385.7 704.0 ± 174.2 761.4 ± 485.9 P = 0.002*
2.2 ± 1.1 2.6 ± 1.9 2.7 ± 1.7 4.6 ± 2.4 4.0 ± 0.6 5.0 ± 1.8 P = 0.021*
65.1 ± 28.3 82.7 ± 26.7 106.8 ± 51.1 103.3 ± 46.6 172.4 ± 21.3 144.6 ± 57.9 P = 0.001*
P = 0.232
P = 0.060
P = 0.734
GP, greater palatine; TN, transnasal; STD, standard deviation; OT, operating time; Avr, average; EBL, estimated blood loss; *, indicates significance; (all P values were performed using Factorial ANOVA).
Our findings solidify the preconceived notion that polyps and prior ESS significantly increase blood loss during ESS [18]. We found a statistically significant increase in EBL in patients with polyposis as well as in revision cases. Overall, the combined injection group benefited from a significantly lower EBL/min than the control group, and trended toward an overall reduced EBL. As endoscopic stage increased, there were statistically significant increases in EBL and OT. However, within each endoscopic stage, statistical significance was not reached. In addition, we found that as CT stage increased (both for the combined and control group), the EBL, EBL/min, and OT had statistically significant increases. Although we found an overall advantage in performing combined GPC and TN injections during ESS, there are several limitations to this study that need to be acknowledged. This study is subject to all the limitations inherent to a retrospective chart review and should be viewed in this context. Additionally, potential selection bias as well as small sample size may have confounded these results. Consequently, these early and promising findings would benefit from validation in the form of prospective randomized double blind studies. Nevertheless, we believe that these results can lay the framework for future investigations.
5.
Conclusion
Our results demonstrate that during ESS the addition of GPC injection to the traditional TN approach trends toward a decrease in overall EBL without reaching statistical significance. This technique appears to be a safe and relatively simple method that may potentially decrease EBL during ESS. We also learned that increased endoscopic and CT stages, presence of polyps, and revision surgery may all significantly lead to greater EBL.
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