Do Preoperative Corticosteroids Benefit Patients with Chronic Rhinosinusitis with Nasal Polyposis?

TRIO Best PracticeTRIO Best Practice articles are brief, structured reviews designed to provide the busy clinician with a handy outline and reference for day-to-day clinical decision making. The ENTtoday summaries below include the Background and Best Practice sections of the original article. To view the complete Laryngoscope articles free of charge, visit Laryngoscope.

Background

Optimizing the surgical field in patients with chronic rhinosinusitis with nasal polyposis (CRSwNP) increases the chances for a safe and efficient surgery. Preoperative medical management, anesthetic choice, patient positioning, and topical vasoconstrictors are methods currently used to mitigate cumbersome bleeding during surgery. Decreased bleeding improves the quality of the optical cavity, thereby enhancing visualization of nearby critical structures.
Pretreatment with corticosteroids is a common practice with the theory that decreased preoperative mucosal inflammation and edema results in less blood loss and better surgical visualization. Several randomized trials have addressed the efficacy of CRSwNP pretreatment with corticosteroids with respect to bleeding loss and surgical field quality.

Best Practice

Preoperative treatment of patients with CRSwNP undergoing endoscopic sinus surgery with corticosteroids is indicated and beneficial. Pretreatment with corticosteroids shortens operative time, likely decreases bleeding, and improves the quality of the surgical field allowing for safe and efficient surgery. There are known risks of administration of systemic corticosteroids, and clinicians must take these into account when evaluating an individual patient. Additionally, future studies are needed to determine the optimal dose and duration of treatment (Laryngoscope. 2019;129:773–774).

Table 1. Summary of Management of Pediatric Obstructive Sleep Apnea

(click for larger image) Table 1. Summary of Management of Pediatric
Obstructive Sleep Apnea

ENT Today

Tranexamic Acid Could Decrease Operative Time, Intraoperative Blood Loss in ESS

How effective is systemic tranexamic acid compared to a control in blood loss, operative time, and surgical field and incidence of postoperative emesis and thromboembolism in endoscopic sinus surgery (ESS)?

Bottom line: The systemic administration of tranexamic acid could decrease operative time and intraoperative blood loss, increasing the satisfaction of surgeons. It did not provoke intraoperative hemodynamic instability, postoperative emetic events, or coagulation profile abnormality.

Background: Because the nose and paranasal sinuses are highly vascularized, surgery there may cause significant bleeding, making identification of important anatomic landmarks and structures difficult, increasing intraoperative complication risks and prolonging operating time. Tranexamic acid can decrease intraoperative bleeding. Although it is usually well tolerated, nausea and vomiting are known common side effects, and hypotension has been observed during rapid intravenous administration.

Study design: Literature review of seven studies comprising 562 participants, comparing perioperative tranexamic acid administration (treatment group) with a placebo (control group).

Setting: PubMed, SCOPUS, Embase, the Web of Science, Google Scholar, and the Cochrane database; search results are from their inception to July 2018.

Synopsis: Outcomes of interest were intraoperative morbidities, including surgical time, operative bleeding, and hypotension; postoperative morbidities such as nausea and vomiting; and coagulation profiles. Operative time, intraoperative blood loss, and the surgical field score were statistically lower in the treatment group than in the control group. Surgeon satisfaction was statistically higher in the treatment group than in the control group. There was no significant difference between the groups in intraoperative blood pressure. The incidence of postoperative nausea and vomiting and thrombotic accident showed no significant differences between the groups. Platelet count, prothrombin time, and partial thromboplastin time showed no significant differences between the groups. In sensitivity analyses that evaluated the differences in the pooled estimates by repeating the meta-analyses with a different study omitted each time, all results were consistent with the outcomes previously found. Limitations included a lack of consideration of external factors such as polyps versus no polyps, revision versus primary, and usage of other hemostatic agents because the analysis was performed based on the statistical measurements of the figures.

Citation: Kim DH, Kim S, Kang H, Jin HJ, Hwang SH. Efficacy of tranexamic acid on operative bleeding in endoscopic sinus surgery: a meta-analysis and systematic review. Laryngoscope. 2019;129:800–807.

ENT Today