Key learning points

Introduction

Endoscopic sinus surgery (ESS) is considered to be a moderate bleeding risk surgery. Bleeding is anticipated during sinonasal surgery when treating inflammatory and vascular disorders, and is due in part to the inherently rich blood supply derived from the external and internal carotid arteries in this region. Expected surgical bleeding is encountered from mucosa, bone and vascular tumors, such as juvenile angiofibroma and metastatic renal cell carcinoma.

Adequate hemostasis of the microvascular and macrovascular circulation is needed during endoscopic or open sinus surgery, performed under local or general anesthesia, to accomplish the surgical goals and avoid complications. A thorough risk assessment is required to prevent excessive bleeding. Correct assessment of the source of the bleeding, and a detailed knowledge of surgical vascular anatomy and of hemostatic techniques, is necessary to successfully manage intraoperative bleeding.

Introduction

Endoscopic sinus surgery (ESS) is considered to be a moderate bleeding risk surgery. Bleeding is anticipated during sinonasal surgery when treating inflammatory and vascular disorders, and is due in part to the inherently rich blood supply derived from the external and internal carotid arteries in this region. Expected surgical bleeding is encountered from mucosa, bone and vascular tumors, such as juvenile angiofibroma and metastatic renal cell carcinoma.

Adequate hemostasis of the microvascular and macrovascular circulation is needed during endoscopic or open sinus surgery, performed under local or general anesthesia, to accomplish the surgical goals and avoid complications. A thorough risk assessment is required to prevent excessive bleeding. Correct assessment of the source of the bleeding, and a detailed knowledge of surgical vascular anatomy and of hemostatic techniques, is necessary to successfully manage intraoperative bleeding.

Approach to hemostasis in sinus surgery

Significant intraoperative bleeding can be minimized by preventive measures preoperatively, intraoperatively, and postoperatively. When bleeding is encountered, either intraoperatively or postoperatively, the surgeon has to be prepared to be able to manage this effectively.

Bleeding prevention: preoperative

For a comprehensive review on the assessment and management of patient comorbid risk factors and medications, please see articles elsewhere in this issue (see Tassler A, Kaye R: Preoperative assessment of risk factors , in this issue; and McKean E: Quality control approach to anticoagulants and transfusion , in this issue). It should be noted that herbal supplements, in particular the 4 Gs (ginseng, garlic, ginger, and gingko biloba), also affect platelet function and should be stopped 10 days (based on the half-life of platelets) before surgery. Saw palmetto and high doses of vitamin E and omega-3 can increase bleeding risk as well.

Rhinitis medicamentosa should be recognized preoperatively and the offending topical decongestant discontinued as soon as possible. To minimize rebound congestion patients should be started on topical saline and corticosteroids. Chronic topical exposure to sympathomimetics (eg, phenylephrine) or imidazolines (eg, oxymetazoline, xylometazoline) causes dysregulation of vascular tone, thus intraoperative topical vasoconstrictors are ineffective in controlling the microvascular circulation. In such situations, tranexamic acid (TXA) (1 mg during induction), which acts to reduce clot breakdown, can be used.

Adequate perioperative management of hypertension is imperative to achieve optimum intraoperative conditions. The risk of surgical bleeding is estimated to increase 1.5-fold with aspirin but for most procedures the severity of bleeding is not increased. In this study, the mean estimated blood loss during ESS in patients on aspirin was slightly higher than in controls, especially when more sinuses were opened. It is generally possible to safely perform ESS in patients on aspirin by using other strategies to manage the surgical field.

Because of the risks associated with a bloody field during ESS and no known reversible agents for aspirin, it is advisable to cease aspirin 10 days earlier. Before stopping aspirin, the risk of doing so needs to be discussed with the patient’s cardiologist or primary care physician because 10% of acute cardiovascular events are preceded by aspirin withdrawal. In at-risk patients, the average time intervals from aspirin cessation to acute stroke and acute coronary syndrome are 14·3 and 8·5 days respectively.

For emergency reversal of the effect of aspirin, donor platelet infusion is effective. In otherwise healthy aspirin-treated individuals, desmopressin (desamino- d -arginine vasopressin [DDAVP]) has been shown to reduce bleeding time, and may be considered intraoperatively in selected situations. However, it is contraindicated in patients at cardiovascular risk and there are no data to support the efficacy of DDAVP in this group.

At present there are insufficient data to make strong recommendations on routine GC use in ESS to improve the surgical field. Despite the limitations of study design and control groups (patient selection, disorder, type of anesthesia, or vasoconstrictor use), there seems to be a trend toward a beneficial effect of preoperative GC in reducing the amount of blood loss during ESS for nasal polyps.

In patients with nasal polyps, a single preoperative dose of 1 mg/kg prednisolone compared with 5 days of therapy may be just as effective in reducing blood loss during ESS. However, a control group without any treatment was not used for comparison. In contrast, a recent randomized controlled study showed no significant hemostatic benefit of preoperative GC. It remains to be seen whether the addition of preoperative GC has a significant benefit in the presence of other hemostatic preventive strategies (eg, adequate patient positioning and general anesthesia conditions). Note also that many anesthetists administer a single dose of dexamethasone during induction for its beneficial effects on perioperative nausea and vomiting, but it may also have an independent positive effect on the surgical field.

Potential vascular hazards can be identified preoperatively by examining high-resolution sinus CT scans systematically. Note that the right and left sides may be asymmetrical. Breaching its boundaries during ESS not only risks serious complications and vascular injury but causes bleeding from surrounding tissues, orbital fat, and dura.

A suggested approach is described, starting off with coronal sections to examine the relationship of the cribriform plate to the frontal recess and ethmoid sinuses, including lateral lamella.

The lamina papyracea can be followed posteriorly into the sphenoid sinus and from the skull base to the level of the roof of the maxillary sinus to look for bone dehiscence in both axial and coronal planes.

Next, determine whether the ethmoid arteries are against the skull base or running within a pedicle suspended below the skull base. This anatomy is best identified on a coronal scan and confirmed with sagittal images. The anterior ethmoid artery (AEA) is more likely to be on a pedicle than the posterior ethmoid arteries. In some patients there is a middle ethmoid artery.

Follow the posterior ethmoid cells and examine their relationship with the sphenoid sinuses. If the posterior ethmoid pneumatization extends beyond the sphenoid sinus (demarcated inferiorly by the choanal roof), it is most likely an Onodi cell, hence closely related to the optic nerve, and in some cases the internal carotid artery (ICA).

The sphenoid sinus should be assessed for the extent of pneumatization, dehiscence, and configuration of the intersinus septum. If the septum is lateralized, it often attaches to bone overlying the ICA. Care needs to be taken when taking down the septum and avoid through-biting instruments and twisting maneuvers closer to its posterior attachment. Here also, the relationship of the pituitary gland and ICA within the sphenoid sinuses can be examined. Determine whether the course of the ICA is predictable or aberrant, and look for vascular malformations, aneurysms, bone dehiscence, and relationship to the posterior ethmoid sinus.

The shape or slope of the skull base can be appreciated on sagittal images. The skull base may be high within the sphenoid sinus, low toward ethmoid sinuses, and high again at the frontal recess and anterior ethmoid sinuses. The extent of low ethmoid skull base can be evaluated in comparison with the adjacent orbital roof height on coronal scans.

In addition, reconfirm that the radiological characteristics are in keeping with the clinical diagnosis. Presence of skull base dehiscence should prompt further assessment with MRI and or CT/MR angiogram to exclude the possibility of disorders such as a vascular tumor (angiofibroma), ICA aneurysm, or meningoencephalocele.

Bleeding prevention: intraoperative

Local Vasoconstrictors

Local agents are widely used in ESS for mucosal vasoconstriction, reduced bleeding, and decongestion. Most surgeons use a combination of local injection and topical application of vasoconstrictors on pledgets within the nose. Although, for injection, usually varying concentrations of adrenaline mixed with a local anesthetic is most commonly used, the choice of topical vasoconstrictor varies considerably between surgeons worldwide.

• •
  

  Allow time to exert its effects

  
  
• •
  

  Atraumatic manner

  
  
• •
  

  Topical application sites (with pledgets (cottonoids, neuropatties or pieces of gauze))

  
  
  
  
  • ○
    

    Root of middle turbinate/middle meatus (sphenopalatine artery)

    
    
  • ○
    

    Sphenoid rostrum (posterior septal artery)

    
    
  • ○
    

    Anterior nasal cavity (working area, mucosal decongestion)

    
    
  • ○
    

    Anterior floor of nose (greater palatine artery at incisive foramen)

  
  
  
  
• •
  

  Injection/infiltration site options include:

  
  
  
  
  • ○
    

    Septum

    
    
  • ○
    

    Inferior turbinate

    
    
  • ○
    

    Anterior buttress (axilla) of middle turbinate

    
    
  • ○
    

    Above axilla of middle turbinate (anterior ethmoid branches)

    
    
  • ○
    

    Root of middle turbinate (sphenopalatine artery)

    
    
  • ○
    

    Sphenoid rostrum (posterior septal artery)

    
    
  • ○
    

    Greater palatine canal via the oral cavity (greater palatine artery, internal maxillary artery within the pterygopalatine fossa)

  
  

What are some technical aspects of local vasoconstrictor application during ESS?

Key factors in the efficacy of local vasoconstrictors are to allow time for its action, usually 15 minutes, with peak effect ∼30 minutes, and an atraumatic technique. If applied soon after induction, it can work while the ESS setup is performed. In addition to the agent used, the sites of vasoconstrictor application should be considered, bearing in mind the hemostatic goals. It is reasonable to suggest that, where possible, vasoconstrictor application should target the major vascular supply to the sinonasal cavities.

• •
  

  Middle turbinate anterior buttress injection

  
  
  
  
  • ○
    

    Bupivacaine 0.25%, 1:200,000 adrenaline

    
    
  • ○
    

    No significant benefit in surgical field or blood loss

  
  
  
  
• •
  

  Middle turbinate, lateral nasal wall, agger nasi region, sphenopalatine foramen

  
  
  
  
  • ○
    

    Adrenaline 1:100,000

    
    
  • ○
    

    No significant benefit in surgical field or blood loss

  
  
  
  
• •
  

  Greater palatine canal injection (via oral cavity)

  
  
  
  
  • ○
    

    Bupivacaine solution (2 mL of 0.5%) injection for compressive effects

    
    
    
    
    • ▪
      

      Reduction of 4.7% in inferior turbinate blood flow

    
    
    
    
  • ○
    

    Xylocaine 1%, 1:100,000 adrenaline

    
    
    
    
    • ▪
      

      No significant benefit in surgical field or blood loss

    
    
    
    
  • ○
    

    Not recommended for routine ESS for this purpose

    
    
  • ○
    

    May have a role in the surgical management of unilateral epistaxis from the sphenopalatine region (posterior epistaxis)

  
  

Only gold members can continue reading. Log In or Register to continue

Share this:

• Click to share on Twitter (Opens in new window)
• Click to share on Facebook (Opens in new window)

Related

Related posts:

1. Hemostatic Materials and Devices
2. Treatment of Hereditary Hemorrhagic Telangiectasia–Related Epistaxis
3. Hemostasis in Otologic and Neurotologic Surgery
4. Management of Carotid Blowout from Radiation Necrosis

Stay updated, free articles. Join our Telegram channel

Join