xRead - Nasal Obstruction (September 2024) Full Articles

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International consensus statement on rhinosinusitis

with targeted ESS. 1780,1781,1818 Image guidance during pri mary surgery has been associated with a reduced rate of revision surgeries, although has not been shown to reduce the risk of complications. 1819 Revision surgery may be required in cases of persistent inflammatory disease or recurrent nasal polyposis and can be an effective tool to produce symptomatic relief. 1820,1821 This may be due to inadequate primary surgical extirpa tion, postoperative scarring and neo-osteogenesis, or inad equate postoperative medical management. 1822 One study identified a revision rate of nearly 20%. 287 An understand ing of both patient and iatrogenic factors as the etiol ogy for persistent disease is critical to determine can didacy and approach for revision surgery. 1822 The tech nical aim is to remove residual bony partitions of all previously addressed and unaddressed sinuses, address scarring, and remove diseased tissue, with additional interventions such as drilling only used after this has been accomplished. 1812,1822,1823 If revision sinus surgery is required, long-term topical therapy is likely necessary, and so the creation of a sinus cavity amenable to this interven tion should be a primary goal. To achieve this goal when revising an otherwise well-done primary surgery, it may be necessary to perform a medial maxillectomy, endoscopic modified Lothrop, or a sphenoid drill-out depending on the patient’s individual sinonasal anatomy. 1822,1824 The poten tial benefits of revision surgery must be weighed against the incidence of CSF and orbital injuries, which have been reported higher in some series. 98,102 Image guidance may be particularly useful in this context to navigate the altered anatomy. 1782,1822,1825 XII.A.4 Anesthesia Technique in Sinus Surgery XII.A.4.a. Total Intravenous Anesthesia (TIVA) vs Inhalational Anesthesia As ESS has advanced over the last 4 decades, the agents used to anesthetize patients undergoing these procedures has similarly evolved. From the early years of ESS, there has been recognition that anesthetic type impacts the amount of blood lost during the procedure. 1826 As bleeding during ESS limits visualization, increases operative time, and risk of complications, appropriate anesthetic selection is imperative. 1827 Today there are 2 anesthetic paradigms in ESS: total intravenous anesthesia (TIVA) and inhala tion anesthesia (IA). Both can be used to lower patients’ blood pressure, a technique called controlled or deliberate hypotension, to reduce bleeding. 1827 Initially described by Blackwell et al., the maintenance phase of TIVA typically consists of a propofol infusion alone or in combination with a short acting opioid such

as remifentanil or fentanyl. 1828 IA relies on inhalation of a halogenated ether such as isoflurane, sevoflurane, or des flurane. Similar to TIVA, IA may be administered alone or in combination with an opioid, as above. 1829 Unlike in IA, TIVA utilizes a central mechanism to reduce periph eral pressures and associated potential for venous bleed ing. Propofol leads to deceased cerebral metabolic rate and lower cerebral blood flow. 1830 This decreased blood flow to the internal carotid artery decreases blood flow to the ethmoidal and supraorbital arteries, potentially decreas ing bleeding in areas supplied by these vessels: the sphe noid, ethmoid, and frontal sinuses. IA, on the other hand, leads to hypotension through peripheral vasodilation. This can lead to increased capillary bleeding. 1831 While initially more costly, TIVA now has a lower cost than IA. 1832 The use of TIVA is also associated with a decreased incidence of early postoperative nausea and vomiting compared with sevoflurane or desflurane in patients undergoing ambula tory surgery. 1833 A total of 17 prospective studies have been under taken to determine if bleeding is reduced during ESS in patients anesthetized with TIVA compared to IA. Four sys tematic reviews, 3 with meta-analyses, have been com pleted. All 3 meta-analysis found that surgical visualiza tion was improved with TIVA. Only Kolia et al. found that estimated blood loss (EBL) and operative time were also reduced. 1834 While many of the recent studies were randomized and blinded, the quality of these studies is low. Particularly problematic is the confounder posed by remifentanil which results in decreased heart rate, cardiac output, and blood pressure without peripheral vasodila tion, all of which may confound study findings. 1829 Addi tional study controlling for the impact of intraoperative opioid should be undertaken. Total Intravenous Anesthesia for ESS Aggregate Grade of Evidence: C (Level 1: 4 studies; level 2: 16 studies; level 3: 1 study; Table XII-1). Benefit: TIVA may improve surgical visualization and reduce blood loss and a decreased incidence of early postoperative nausea and vomiting com pared to IA with sevoflurane or desflurane. Harm: No evidence of increased risk with TIVA. Cost: TIVA may have a lower cost than IA in some health systems and a higher cost in others. Benefits-Harm Assessment: Preponderance of benefit over harm. Value Judgments: TIVA appears to display sev eral advantages over IA, however local prac tice patterns, drug supplies, individual patient