Topical Epinephrine

Epinephrine has been used as a hemostatic agent in surgical procedures for many years. It is inexpensive and easily applied to the surgical field, and has excellent hemostatic properties. However, it has the potential to cause severe complications, such as tachycardia, hypotension, hypertension, and cardiac arrhythmias. Hypertension and tachycardia historically are the most commonly observed complications, especially combined with the use of volatile anesthetics such as halothane. However, the combination of topical or injected epinephrine with newer anesthetics, either intravenous (eg, propofol) or volatile (eg, enflurane), has significantly reduced the occurrence of serious side effects. Recently, use of topical epinephrine in endoscopic sinus and skull base surgery has experienced resurgence.

Despite obvious advantages, few studies have evaluated epinephrine’s effects on blood loss, systemic levels from topical application, and the ideal concentration for topical use. In 2009, Sarmento Junior and colleagues evaluated varying concentrations of topical adrenaline, including 1:2000, 1:10,000, and 1:50,000. The results of their prospective study showed that the 1:2000 group had a statistically significant decrease in blood loss (objective and subjective measures) and shorter operative times. Plasma levels of epinephrine increased in all categories, but more sharply in the 1:2000. Although a trend was seen toward increasing blood pressure in the 1:2000 and 1:10,000 groups, this rise was slow and no adverse events were reported. The authors concluded that 1:2000 epinephrine provided superior hemostasis with minimal risk.

In another recent study, Cohen-Kerem and colleagues evaluated the use of epinephrine/Lidocaine injection versus saline during endoscopic sinus surgery. They measured plasma epinephrine concentrations and surprisingly found that the saline injection group had higher levels 15 minutes after injection. Subjectively, the surgical field had more bleeding in the saline injected group, but the objective findings showed no statistical difference.

The authors’ practice routinely uses epinephrine-soaked cotton pledgets to aid with hemostasis. Their preferred concentration is 1:1000, which has provided excellent hemostasis with limited side effects. Prospective trials of large cohorts evaluating ideal concentration and incidence of adverse events are warranted.

Other Topical Hemostatic Agents

In addition to topical epinephrine, numerous absorbable substances have been introduced to aid hemostasis in sinus and skull base surgery. Within the confines of the sinus and nasal cavities, ideal hemostatic agents must have several specific qualities. They must provide hemostasis, conform to an irregular wound bed, and enable healing of the traumatized mucosa without additional detriment to the epithelium. Traditional nasal packing has been substituted largely by absorbable materials designed to improve patient comfort and outcomes. Although many promising agents exist, none have become standard therapy.

Merogel (Medtronic-Xomed, Jacksonville, FL, USA) is a hyaluronic acid ester derivative. It has been used in functional endoscopic sinus surgery as a hemostatic agent and a middle meatal spacer. It was one of the first absorbable materials introduced and has become somewhat of a standard against which newer materials are compared.

In a prospective single-blind randomized control study in 2006, Wormald and colleagues compared nasal cavities packed with Merogel versus no packing. They concluded that the Merogel nasal pack has no significant beneficial or detrimental effect in terms of synechia, edema, or infection when placed in the middle meatus after endoscopic sinus surgery. Recently, Berlucchi and colleagues compared Merogel with traditional nasal packing and showed that Merogel was associated with an improved appearance during nasal endoscopy, fewer adhesions, and improved patient comfort. Merogel has clearly been shown to have no adverse effects on nasal mucosa when used after endoscopic sinus surgery; however, its benefits in terms of long-term outcomes are less apparent.

Sepragel (Genzyme Biosurgery, Cambridge, MA, USA) is a hylan B gel (cross-linked hyaluronic acid molecule) that can be injected into the nasal cavity after endoscopic sinus surgery. Good evidence of its hemostatic properties is not available, but it has been used as a resorbable packing to improve outcomes after endoscopic sinus surgery.

In a trial evaluating postoperative changes after ethmoidectomy with and without the application of Sepragel, Kimmelman and colleagues showed that Sepragel application was associated with a decrease in middle meatal stenosis and synechiae formation, and improved appearance of the nasal mucosa. However, their patient sample size was small and no further studies have shown a clear benefit.

FloSeal (Baxter Healthcare Corporation, Fremont, CA, USA) is a paste of bovine gelatin particles combined with thrombin that can be injected into the sinus cavities. Multiple studies have shown the ability of FloSeal to create hemostasis. Reported bleeding cessation times range from 2.0 to 16.4 minutes. When compared with Merogel, which is a nonabsorbable, highly porous, polyvinyl acetal sponge, intraoperative hemostasis was obtained within 3 minutes in both groups.

In addition to its hemostatic properties, evidence shows that postoperative packing with FloSeal does not result in significant patient discomfort. However, concern has been raised regarding increased formation of middle meatal adhesions. When severe, these can cause obstruction of sinus outflow tracts and require revision surgery.

In an initial series in 2003 and a follow-up in 2005 comparing FloSeal with thrombin-soaked gelfoam, Chandra and colleagues found a significantly higher number of adhesions in the FloSeal group. Furthermore, in a retrospective analysis of patients who underwent middle turbinate medialization with or without the application of FloSeal, Shrime and colleagues showed that FloSeal was associated with a statistically significant increase in the number of adhesions formed. Thus, solid evidence indicates that FloSeal aids in both intraoperative and postoperative hemostasis, but application of this product increases the risk for adhesion formation.

Surgiflo hemostatic matrix (Ethicon, Inc, West Sommerville, NJ, USA) is a sterile, absorbable porcine gelatin that is combined with Thrombin-JMI (King Pharmaceuticals, Inc, Bristol, TN, USA). The combination of the two materials results in a material that is injectable and conforms to an irregular wound bed. In 2009, Woodworth and colleagues reported on a multicenter, prospective study evaluating success of achieving hemostasis within 10 minutes of Surgiflo application. The study population included patients undergoing primary or revision endoscopic sinus surgery. Bleeding was controlled within 10 minutes in 96.7% of cases and the mean total time to hemostasis was 61 seconds. At 30-day follow up, no evidence of synechiae, adhesions, or infections was seen. Surgiflo is an agent that seems to have very good hemostatic properties; however randomized, controlled trials with long-term follow-up are indicated.

Antifibrinolytics have been in widespread medical use since the 1970s. Epsilon-aminocaproic acid (EACA; Amicar, Lederle Parenterals, Inc, Caroline, Puerto Rico, USA) and tranexamic acid (TA; Cyklokapron, Pfizer, Puurs, Belgium) are pharmaceuticals that competitively bind to lysine-binding sites on plasminogen, preventing the binding of plasminogen to fibrin, its subsequent activation, and the transformation to plasmin. This action prevents fibrinolysis and stabilization of blood clots.

In a study evaluating the hemostatic effects of EACA and TA during endoscopic sinus surgery, Athanasiadis and colleagues applied both agents topically and documented bleeding using standardized videoendoscopy and grading scales. The administration of TA resulted in improved surgical field bleeding at 2, 4, 6, and 8 minutes. However, no significant improvements in surgical field bleeding were seen with EACA. No adverse events were reported with the use of either substance. The results of this limited experience warrant further trials to better determine the effects of TA in endoscopic sinus surgery.

Seprapak (Genzyme, Cambridge, MA, USA) contains a combination of hyaluronic acid and carboxymethyl cellulose. It is packaged as a solid wafer that is inserted into the middle meatus and converted into a gel with saline irrigation. A multicenter, randomized, controlled trial compared Seprapak with no packing in a series of 53 patients undergoing surgery for chronic rhinosinusitis. The primary outcome measure was formation of adhesions. The results of this study showed no long-term difference in formation of adhesions between the groups. However, fewer adhesions at 2 weeks were seen in the Seprapak group, suggesting that packing with Seprapak may reduce the amount of postoperative debridement needed after endoscopic sinus surgery.

Microporous polysaccharide hemospheres (MPH; Medafor, Inc, Minneapolis, MN, USA) are particles produced from purified potato starch that act as a molecular sieve to quickly extract fluids from blood. This osmotic action causes the microporous particles to swell and concentrate serum proteins, platelets, and other formed elements on their surfaces, thereby generating scaffolding for fibrin clot formation. Additionally, MPH is fully resorbed and enzymatically cleared from the wound site within 24 to 48 hours.

In 2008, Antisdel and colleagues published their evaluation of MPH versus FloSeal in the nasal mucosa of New Zealand white rabbits. In this study, the sinus and nasal mucosa was stripped and one side was treated with either FloSeal or MPH, and the other side served as an untreated control. After 2 weeks, animals were euthanized and the surgical site was examined grossly and histologically. The MPH-treated group showed no evidence of remaining substance, and histologically the mucosa resembled that of the untreated mucosa. In contrast, regenerating mucosa treated with FloSeal showed extensive loss of cilia, inflammation, and fibrosis. Residual FloSeal particles were present in the sinus cavity and grossly incorporated within healing mucosa. The results of this study introduced an exciting new material for potential use in endoscopic sinus surgery. Prospective, randomized trials are required to evaluate effects in a human population.

Coblation

Radiofrequency coblation technology (the Coblator; ArthroCare ENT, Austin, TX, USA) was first introduced for use in otolaryngology for tonsil and turbinate surgery. This device uses a bipolar radiofrequency-based plasma process. Radiofrequency energy excites electrolytes in a conductive medium, such as saline, creating precisely focused plasma. The energized particles in the plasma have sufficient energy to break molecular bonds, excising or dissolving tissue at a relatively low temperature, thereby preserving the integrity of surrounding tissue. In contrast to electrocautery, which operates at temperatures of 400°C to 600°C, the Coblator operates at between 40°C and 70°C. Working at lower temperatures, the Coblator causes less collateral damage to surrounding tissues, and thus represents a potentially useful instrument within the confines of the sinus and nasal cavities.

The Coblator has shown clinical effectiveness in removing soft tissue within the sinus and nasal cavities, including adenoids, nasopharyngeal angiofibromas, sinonasal polyposis, and turbinate reduction. Recently, Eloy and colleagues investigated blood loss in endoscopic sinus surgery for nasal polyposis using traditional techniques compared with coblation. They found that coblation-assisted nasal polypectomy was associated with a statistically significant lower estimated blood loss and blood loss per minute when compared with the traditional microdebrider removal.

Although nasal polyps have been removed using endoscopy since the inception of endoscopic sinus surgery, sinonasal and anterior skull base neoplasms have traditionally been removed through open surgical approaches, such as a lateral rhinotomy and craniofacial resection. As expertise in using endoscopy to treat inflammatory disease has increased, a natural progression has occurred toward applying these techniques for removing sinonasal and skull base neoplasms.

One of the largest impediments to endoscopic removal of skull base neoplasms has been poor visualization secondary to inadequate control of intraoperative bleeding. Unfortunately, many sinonasal and skull base neoplasms have a robust vascular supply. Debulking these tumors facilitates visualization of tumor attachment sites and increases working space within the sinus cavities. In the past, the microdebrider has been an extremely effective instrument for debulking these tumors, but profuse bleeding is common. The characteristics of the Coblator allow removal of soft tissue and coagulation simultaneously, thus making it an ideal instrument for tumor debulking.

In the authors’ experience, the Coblator has become an invaluable tool for tumor debulking in the sinus and nasal cavities. In a review of 23 patients who underwent endoscopic removal of sinonasal or skull base tumors, the coblation device was used in 10 patients ( Fig. 1 ) and the microdebrider in the remaining cases ( Fig. 2 ). Various data points were collected, including complications and blood loss. Additionally, full operative videoendoscopy was available for all cases and intraoperative bleeding scored using the 11-point Wormald Surgical Field Grading Scale. Findings showed that the Coblator was associated with significantly lower blood loss (350 vs 1000 mL; P = .00001), estimated blood loss divided by operative time (66 vs 166 mL/h; P = .0001), and Wormald grade (3.3 vs 6.4; P = .0001).

( A ) Coronal contrasted MRI showing a malignant melanoma of the skull base. ( B ) The same tumor after debulking using the Coblator.

( A ) Coronal T1-weighted MRI shows a large esthesioneuroblastoma. ( B ) The bloody field generated by tumor debulking with the microdebrider.

In addition to tumor debulking and removal, the Coblator is an excellent tool for reducing and removing encephaloceles. A prospective evaluation of Coblator-assisted endoscopic removal of 13 encephaloceles in 11 patients compared with 7 encephaloceles reduced with traditional bipolar cautery showed that duration of removal was significantly lower in the Coblator group (21.5 vs 65.1 min; P = .013), with similar hemostatic properties. Additionally, the authors are now using the Coblator to raise nasoseptal and turbinate flaps for skull base reconstruction.

The limitations of the Coblator are largely caused by the size of the wand and the saline delivery system. The function of the Coblator depends on the presence of a conductive medium. Often when using the device in the sinus and nasal cavities, especially the anterior skull base, the device must be held vertically. This positioning reduces the presence of the conductive medium and causes a reduction in the effectiveness of the device. In most instances this can be overcome by increasing the irrigation delivered. The size of the wand has not been an impediment for debulking tumors or nasal polyposis, but as the indications in the sinuses increase, designs will require even more specificity for endoscopic sinus procedures.

Hydrodebrider

Despite significant advances in surgical technology and technique, chronic rhinosinusitis remains difficult to control. Multiple studies have shown the presence of bacterial biofilms in patients with this condition. Prevailing theories believe that the protection conferred to bacteria from encasing themselves in a self-produced exopolymeric matrix, called a biofilm, provides them with a method of evading host defenses and facilitates their successful colonization of the sinus and nasal cavities. The protection of the matrix results in strong antimicrobial resistance to conventional medical and surgical treatments.

Methods for eliminating biofilms have become an active area of investigation. Chiu and colleagues evaluated 1% baby shampoo irrigations in vitro and in a prospective clinical trial. Baby shampoo is a chemical surfactant that could theoretically reduce the surface tension of thick inspissated mucus, thereby facilitating its clearance, but also potentially break up biofilms from the detergent action. In vitro, 1% baby shampoo prevented the formation of new Pseudomonas aeruginosa biofilms, but did not eliminate preformed biofilms. Clinically, most patients noted an improvement in their symptoms. Other substances investigated include mupirocin, citric acid combined with a zwitterionic surfactant (CAZS), and gallium nitrate. All investigations have met with limited success. In 2004, a comprehensive consensus document from five professional otorhinolaryngology societies (The American Academy of Allergy, Asthma and Immunology; the American Academy of Otolaryngic Allergy; the American Academy of Otolaryngology-Head and Neck Surgery; the American College of Allergy, Asthma and Immunology; and the American Rhinologic Society) suggested that elimination of biofilms in patients with chronic rhinosinusitis may require mechanical removal.

In 2007, Desrosiers and colleagues investigated several therapeutics for biofilm removal and their delivery under pressure. CAZS delivered under pressure resulted in the greatest clearance of biofilms in this model. Medtronic subsequently released the Hydrodebrider system as a method for mechanical removal of biofilms and other debris from the sinus and nasal cavities. The Hydrodebrider consists of an endoscopic suction irrigator with 270° articulation designed to apply irrigation under pressure during endoscopic sinus surgery.

Although initial in vitro studies were encouraging, benefit has not been established in clinical trials because an adequate chemical surfactant safe for human use has not been identified. Additionally, little evidence shows the device’s long-term therapeutic benefit for chronic rhinosinusitis. However, the Hydrodebrider is currently being used to clear fungal mucin in individuals with allergic fungal rhinosinusitis and during revision surgery in patients with cystic fibrosis for removing purulent debris. Fungal debris or thick inspissated secretions can be eliminated with minimal trauma to the underlying sinonasal mucosa. Continuing investigations of chemical surfactants and the long-term benefits of this system are warranted.

Ultrasonic Aspirator

The ultrasonic aspirator has been used in neurosurgical procedures for the emulsification and removal of cerebellopontine angle tumors, such as acoustic neuromas. The device has also been used for intracranial lesions, such as gliomas, metastatic brain tumors, and meningiomas. Intraoral procedures such as tongue reduction and tumor resection are also described. The ultrasonic aspirator performs tissue dissection through the ultrahigh frequency movement of the handpiece tip, removing soft tissue and bone through varying the frequency and power.

In 2007, Samy and colleagues reported on using the ultrasonic aspirator to decompress the facial nerve in cadaveric models. Because the instrument does not rotate like a standard otologic burr, it is less likely to cause tissue damage to surrounding nerve or dura. Although the tissue removal properties could make its use desirable in the sinus and nasal cavities, applicability has been difficult secondary to instrument design.

In 2003, Yamasaki and colleagues reported on a new handpiece designed by Sonopet (M and M Co, Ltd, Tokyo, Japan). The new design was used successfully in transsphenoidal surgery. Despite their initial reports, this device has not become a standard instrument in transsphenoidal surgery. Because it is able to remove various tissue types, including bone, the ultrasonic aspirator deserves further investigation in endoscopic sinus and skull base surgery.

Coblation

Radiofrequency coblation technology (the Coblator; ArthroCare ENT, Austin, TX, USA) was first introduced for use in otolaryngology for tonsil and turbinate surgery. This device uses a bipolar radiofrequency-based plasma process. Radiofrequency energy excites electrolytes in a conductive medium, such as saline, creating precisely focused plasma. The energized particles in the plasma have sufficient energy to break molecular bonds, excising or dissolving tissue at a relatively low temperature, thereby preserving the integrity of surrounding tissue. In contrast to electrocautery, which operates at temperatures of 400°C to 600°C, the Coblator operates at between 40°C and 70°C. Working at lower temperatures, the Coblator causes less collateral damage to surrounding tissues, and thus represents a potentially useful instrument within the confines of the sinus and nasal cavities.

The Coblator has shown clinical effectiveness in removing soft tissue within the sinus and nasal cavities, including adenoids, nasopharyngeal angiofibromas, sinonasal polyposis, and turbinate reduction. Recently, Eloy and colleagues investigated blood loss in endoscopic sinus surgery for nasal polyposis using traditional techniques compared with coblation. They found that coblation-assisted nasal polypectomy was associated with a statistically significant lower estimated blood loss and blood loss per minute when compared with the traditional microdebrider removal.

Although nasal polyps have been removed using endoscopy since the inception of endoscopic sinus surgery, sinonasal and anterior skull base neoplasms have traditionally been removed through open surgical approaches, such as a lateral rhinotomy and craniofacial resection. As expertise in using endoscopy to treat inflammatory disease has increased, a natural progression has occurred toward applying these techniques for removing sinonasal and skull base neoplasms.

One of the largest impediments to endoscopic removal of skull base neoplasms has been poor visualization secondary to inadequate control of intraoperative bleeding. Unfortunately, many sinonasal and skull base neoplasms have a robust vascular supply. Debulking these tumors facilitates visualization of tumor attachment sites and increases working space within the sinus cavities. In the past, the microdebrider has been an extremely effective instrument for debulking these tumors, but profuse bleeding is common. The characteristics of the Coblator allow removal of soft tissue and coagulation simultaneously, thus making it an ideal instrument for tumor debulking.

In the authors’ experience, the Coblator has become an invaluable tool for tumor debulking in the sinus and nasal cavities. In a review of 23 patients who underwent endoscopic removal of sinonasal or skull base tumors, the coblation device was used in 10 patients ( Fig. 1 ) and the microdebrider in the remaining cases ( Fig. 2 ). Various data points were collected, including complications and blood loss. Additionally, full operative videoendoscopy was available for all cases and intraoperative bleeding scored using the 11-point Wormald Surgical Field Grading Scale. Findings showed that the Coblator was associated with significantly lower blood loss (350 vs 1000 mL; P = .00001), estimated blood loss divided by operative time (66 vs 166 mL/h; P = .0001), and Wormald grade (3.3 vs 6.4; P = .0001).

( A ) Coronal contrasted MRI showing a malignant melanoma of the skull base. ( B ) The same tumor after debulking using the Coblator.

( A ) Coronal T1-weighted MRI shows a large esthesioneuroblastoma. ( B ) The bloody field generated by tumor debulking with the microdebrider.

In addition to tumor debulking and removal, the Coblator is an excellent tool for reducing and removing encephaloceles. A prospective evaluation of Coblator-assisted endoscopic removal of 13 encephaloceles in 11 patients compared with 7 encephaloceles reduced with traditional bipolar cautery showed that duration of removal was significantly lower in the Coblator group (21.5 vs 65.1 min; P = .013), with similar hemostatic properties. Additionally, the authors are now using the Coblator to raise nasoseptal and turbinate flaps for skull base reconstruction.

The limitations of the Coblator are largely caused by the size of the wand and the saline delivery system. The function of the Coblator depends on the presence of a conductive medium. Often when using the device in the sinus and nasal cavities, especially the anterior skull base, the device must be held vertically. This positioning reduces the presence of the conductive medium and causes a reduction in the effectiveness of the device. In most instances this can be overcome by increasing the irrigation delivered. The size of the wand has not been an impediment for debulking tumors or nasal polyposis, but as the indications in the sinuses increase, designs will require even more specificity for endoscopic sinus procedures.

Hydrodebrider

Despite significant advances in surgical technology and technique, chronic rhinosinusitis remains difficult to control. Multiple studies have shown the presence of bacterial biofilms in patients with this condition. Prevailing theories believe that the protection conferred to bacteria from encasing themselves in a self-produced exopolymeric matrix, called a biofilm, provides them with a method of evading host defenses and facilitates their successful colonization of the sinus and nasal cavities. The protection of the matrix results in strong antimicrobial resistance to conventional medical and surgical treatments.

Methods for eliminating biofilms have become an active area of investigation. Chiu and colleagues evaluated 1% baby shampoo irrigations in vitro and in a prospective clinical trial. Baby shampoo is a chemical surfactant that could theoretically reduce the surface tension of thick inspissated mucus, thereby facilitating its clearance, but also potentially break up biofilms from the detergent action. In vitro, 1% baby shampoo prevented the formation of new Pseudomonas aeruginosa biofilms, but did not eliminate preformed biofilms. Clinically, most patients noted an improvement in their symptoms. Other substances investigated include mupirocin, citric acid combined with a zwitterionic surfactant (CAZS), and gallium nitrate. All investigations have met with limited success. In 2004, a comprehensive consensus document from five professional otorhinolaryngology societies (The American Academy of Allergy, Asthma and Immunology; the American Academy of Otolaryngic Allergy; the American Academy of Otolaryngology-Head and Neck Surgery; the American College of Allergy, Asthma and Immunology; and the American Rhinologic Society) suggested that elimination of biofilms in patients with chronic rhinosinusitis may require mechanical removal.

In 2007, Desrosiers and colleagues investigated several therapeutics for biofilm removal and their delivery under pressure. CAZS delivered under pressure resulted in the greatest clearance of biofilms in this model. Medtronic subsequently released the Hydrodebrider system as a method for mechanical removal of biofilms and other debris from the sinus and nasal cavities. The Hydrodebrider consists of an endoscopic suction irrigator with 270° articulation designed to apply irrigation under pressure during endoscopic sinus surgery.

Although initial in vitro studies were encouraging, benefit has not been established in clinical trials because an adequate chemical surfactant safe for human use has not been identified. Additionally, little evidence shows the device’s long-term therapeutic benefit for chronic rhinosinusitis. However, the Hydrodebrider is currently being used to clear fungal mucin in individuals with allergic fungal rhinosinusitis and during revision surgery in patients with cystic fibrosis for removing purulent debris. Fungal debris or thick inspissated secretions can be eliminated with minimal trauma to the underlying sinonasal mucosa. Continuing investigations of chemical surfactants and the long-term benefits of this system are warranted.

Ultrasonic Aspirator

The ultrasonic aspirator has been used in neurosurgical procedures for the emulsification and removal of cerebellopontine angle tumors, such as acoustic neuromas. The device has also been used for intracranial lesions, such as gliomas, metastatic brain tumors, and meningiomas. Intraoral procedures such as tongue reduction and tumor resection are also described. The ultrasonic aspirator performs tissue dissection through the ultrahigh frequency movement of the handpiece tip, removing soft tissue and bone through varying the frequency and power.

In 2007, Samy and colleagues reported on using the ultrasonic aspirator to decompress the facial nerve in cadaveric models. Because the instrument does not rotate like a standard otologic burr, it is less likely to cause tissue damage to surrounding nerve or dura. Although the tissue removal properties could make its use desirable in the sinus and nasal cavities, applicability has been difficult secondary to instrument design.

In 2003, Yamasaki and colleagues reported on a new handpiece designed by Sonopet (M and M Co, Ltd, Tokyo, Japan). The new design was used successfully in transsphenoidal surgery. Despite their initial reports, this device has not become a standard instrument in transsphenoidal surgery. Because it is able to remove various tissue types, including bone, the ultrasonic aspirator deserves further investigation in endoscopic sinus and skull base surgery.