Abstract
Endoscopic sinus surgery (ESS) is one of the common ENT surgeries performed. Various techniques are available for reducing the blood loss during ESS. The efficacy of cauterization of the SPA in reducing the per-operative blood loss has not been explored in the literature. This study evaluates the efficacy of SPA cauterization prior to sinus surgery and its per-operative and post-operative outcomes. To study the outcomes of endonasal SPA cauterization in patients undergoing ESS. This is a prospective observational study conducted in a tertiary care centre from October 2018 to October 2020. 30 patients underwent ESS where SPA was cauterized by bipolar diathermy in one side of the nasal cavity and in the contralateral side, SPA was not cauterized. The results were tabulated and compared between the cauterized and non cauterized side. p value < 0.05 was considered as statistically significant. Mean blood loss (p value = 0.20), operating time (p value = 0.19), surgical field grade, post operative Lund Kennedy Score at 1st, 4th and 12th week were compared and the difference between cauterized and non cauterized was found to be statistically insignificant. In this study, endonasal SPA cauterization did not significantly reduce the intra operative bleeding and surgical field grade in patients undergoing ESS. SPA cauterization did not adversely affect the per operative and post operative outcome and hence authors highlight the fact that it can be safely performed in cases where severe intra operative bleeding is expected and its effectiveness can be studied better in such cases.
Keywords: Sphenopalatine artery cauterization, Endoscopic sinus surgery, Per operative blood loss, Lund Kennedy score
Introduction
Endoscopic sinus surgery (ESS) is a minimally invasive surgical procedure which mainly aims to improve sinus ventilation by improving the drainage pathways [1]. The procedure is generally used to treat Chronic rhinosinusitis, Sinonasal polyposis not responding to medical treatment [2]. One of the major persistent problem that prevents us from achieving these goals during sinus surgery is intraoperative bleeding [3]. ESS is considered to be a moderate risk bleeding surgery and bleeding is anticipated when treating inflammatory conditions [3].
There are numerous ways described to reduce bleeding during the sinus surgery i.e. adequate premedication and control of hypertension, hypotensive anaesthesia throughout the procedure and correct positioning of the patient during surgery [4, 5]. Control of bleeding during ESS is of prime importance as even a minimal bleed can obscure the surgical field mandating the frequent use of suction and thereby prolonging the operating time [3]. Intra operative bleeding also increases the risk of serious iatrogenic trauma such as orbital and skull base injury which may lead to intraorbital complications and cerebrospinal fluid leak respectively due to poor visualisation of the operating field [6].
Majority of the bleeding during ESS is due to the branches of the Sphenopalatine artery (SPA) which supplies most of the nasal cavity [7]. The role of endonasal SPA cauterisation by bipolar diathermy in controlling the per operative blood loss during ESS has not been explored so far. This study evaluates the efficacy of SPA cauterisation prior to definitive surgery on per-operative blood loss and post-operative outcomes in patients undergoing ESS.
Materials and Methods
This is a prospective observational study conducted in Department of Otorhinolaryngology and Head and Neck Surgery in a tertiary care centre from October 2018−2020. Institutional Ethics Committee approval was obtained and 30 patients were included in this study. Inclusion criteria includes patients with chronic rhinosinusitis with or without polyposis in the age group of 18–60 years. Exclusion criteria includes patients with unilateral sinonasal disease, extensive sinonasal polyposis, benign and malignant tumors of nasal cavity, patients with bleeding disorders or coagulation disorders, uncontrolled diabetes, hypertension, on steroids, chemotherapy, radiotherapy or immunomodulators for any auto-immune diseases and revision surgeries.
All the patients underwent routine baseline investigations, Diagnostic Nasal Endoscopy (DNE) and Non-Contrast Computed Tomography of nose and paranasal sinuses (NCCT). Based on the preoperative DNE findings, the severity of the disease load was calculated using Lund Kennedy scoring. Preoperative disease load was also calculated by assessing the severity of the disease on a CT scan and scoring was based on Lund Mackay scores. Informed consent for the study was obtained from all the patients before surgery.
Out of 30 patients, 15 were cauterized on the right side and 15 were cauterized on the left side of the nasal cavity. Blood loss was measured from each side of the nasal cavities separately. Assessment on the side of SPA cauterization was taken as side A and assessment on the side without SPA cauterization was taken as side B. In each side of the nasal cavity, chronic rhinosinusitis without polyps and with polyps were subcategorized and denoted as P0, P1 respectively.
Intra operatively, Crista ethmoidalis is identified and an incision is made inferior to it. Sphenopalatine foramen along with nerve and artery is identified (Fig. 1), SPA cauterised using bipolar diathermy (Fig. 2). Nasopharyngeal pack placed and surgery completed on one side of nasal cavity. Nasopharyngeal pack changed and surgery on other side of nasal cavity completed.
Fig. 1.
Identification of Sphenopalatine artery
Fig. 2.
Cauterization of the sphenopalatine artery using bipolar diathermy
Total amount of blood loss on one side of nasal cavity = Total amount of fluid collected in suction jar—(Amount of irrigation fluid used in the intravenous bag and tubing for microdebrider + Amount of irrigation fluid used for wash). Both the nasal cavities were packed with ivalon nasal pack and removed on post operative day 1. Both the side of the nasal cavities were watched for post operative bleeding and requirement of re-packing. They were followed up at 1st, 4th and 12th week and both sides of nasal cavities were compared endoscopically using Lund Kennedy Score.
Results
Majority of the study participants were in the age group of 31–40 years. Mean age of the study participants was found to be 35.4 ± 8.3 (SD) years. 16 patients were male (53.4) and 14 patients were female (46.6). 15 patients (50%) underwent SPA cauterization on right side and 15 patients (50%) underwent SPA cauterization on left side of nasal cavity (Table 1).
Table 1.
Side of SPA cauterization with and without polyposis
| Side A SPA cauterized | Side A-P0 (without polyposis) N (%) | Side A-P1 (with polyposis) N (%) | Total N (%) |
|---|---|---|---|
| Left side | 8 (26.7) | 7 (23.3) | 15 (50) |
| Right side | 12 (40) | 3 (10) | 15 (50) |
| Total | 20 (66.7) | 10 (33.3) | 30 (100) |
Average blood loss on the cauterized and non cauterized side of the nasal cavity were measured separately. It was observed that the average blood loss in the cauterized side was 64.7 ± 24.2 ml and non cauterized side was 73.0 ± 26.01 ml. The cauterized side showed a marginally less blood loss than the non cauterized side, though this was not statistically significant (p value = 0.20). In patients with polyposis, the average blood loss in the cauterized and non cauterized side was 91.0 ± 20.9 ml (A-P1) and 102.0 ± 21.1 ml (B-P1) and there was no statistically significant difference (p value = 0.25). In patients without polyposis, the average blood loss in the cauterized and non cauterized side was 51.5 ± 11.8 ml (A-P0) and 58.5 ± 12.6 ml (B-P0) and there was no statistically significant difference. (p value = 0.08) (Table 2).
Table 2.
Per operative blood loss between the cauterized and non cauterized sides (ml) and in subgroups
| Side | Mean | Standard deviation | p value | |
|---|---|---|---|---|
| Per operative blood loss | A (Cauterized) | 64.7 | 24.2 | 0.20 |
| B (Non-cauterized) | 73.0 | 26.01 | ||
| Without polyposis in Side A and B | A-P0 | 51.5 | 11.8 | 0.08 |
| B-P0 | 58.5 | 12.6 | ||
| With polyposis in Side A and B | A-P1 | 91.0 | 20.9 | 0.25 |
| B-P1 | 102.0 | 21.1 |
Intra-operative surgical field score was assessed on the SPA cauterized and non cauterized side. It has been observed that all patients in both the cauterized and non cauterized side had a Boezaart score of less than 3. Thus none of the patient in both groups has moderate to severe bleeding. It was also noted that the surgical field score was better in the side of cauterization at the beginning of the surgery but at 60 min there was no difference in both the sides. There was no statistically significant difference observed between the sides at any part of time during the duration of surgery (Table 3).
Table 3.
Comparison of intra operative surgical field score between the cauterized and non cauterized side
| Surgical field score | 30 Min | 60 min | 90 min | |||
|---|---|---|---|---|---|---|
| A (Cauterized) | B (Non cauterized) | A (Cauterized) | B (Non cauterized) | A (Cauterized) | B (Non cauterized) | |
| NA | 0 | 0 | 0 | 0 | 15 | 20 |
| Slight bleeding—no suctioning | 20 | 12 | 0 | 0 | 9 | 4 |
| Slight bleeding—occasional suctioning | 10 | 18 | 20 | 22 | 5 | 3 |
| Slight bleeding—frequent suctioning | 0 | 0 | 10 | 8 | 1 | 3 |
| Total | 30 | 30 | 30 | 30 | 30 | 30 |
| p value | 0.073 | 0.423 | 0.522 | |||
The total mean time in side A and side B was 65.2 ± 11.7 min and 58.6 ± 10.9 min, respectively and the difference was found to be statistically significant. (p value = 0.02) The mean time taken for cauterization of sphenopalatine artery on one side was 11.86 min.
If time taken to cauterize the SPA is excluded, mean operating time between the cauterized and non cauterized side showed no statistical significance (Table 4).
Table 4.
Operating time between the cauterized and non cauterized side (minutes)
| Operating time | Side | Mean | Standard deviation | p value |
|---|---|---|---|---|
| Including time taken to cauterize SPA | A | 65.2 | 11.7 | 0.02 |
| B | 58.6 | 10.9 | ||
| Excluding time taken to cauterize SPA | A | 53.1 | 10.7 | 0.19 |
| B | 58.6 | 10.9 |
Post-operative healing on the cauterized and non cauterized side assessed endoscopically using Lund Kennedy score at 1st, 4th and 12th week showed no statistically significant difference. Sphenopalatine artery cauterization did not affect the wound healing process during the post operative period. There was no adverse event or complication observed in the post operative follow up in both the cauterized and non cauterized side.
Discussion
Chronic rhinosinusitis is as inflammatory disease of the paranasal sinus lasting for more than 12 weeks, which may or may not be associated with nasal polyps. Nasal congestion and olfactory abnormalities are more typically associated with CRSwNPs, whereas CRSsNPs is more typically characterized by rhinorrhea and facial discomfort [8]. Inflammatory changes in the nasal mucosa contribute to increased bleeding during sinus surgery. Intraoperative bleeding and surgical field quality during ESS depend on the microvasculature density of nasal mucosa. Achieving adequate haemostasis is of vital importance during ESS for proper visualization and avoiding complications. Nasal cavity as such is a highly vascular region and majority of blood supply is from sphenopalatine artery [7]. Bleeding in the surgical field is dependent on a number of factors mainly severity of disease and patient comorbidities such as hypertension and coagulation disorders. There are various well described and developed strategies to minimize intra-operative bleeding thereby improving the surgical outcome.
In general compared to overall prevalence of chronic rhinosinusitis, women are more commonly affected than males. Study by Won et al. [9] showed that the prevalence of CRSwNPs increases after 40 years of age and CRSsNPs is more prevalent in subjects below 40 years of age. Study by Busaba et al. [10] showed that men have a higher prevalence of CRS with nasal polyposis (CRSwNPs), whereas women have higher rates of CRS without nasal polyposis (CRSsNPs).
Increased vasculature of nasal mucosa predispose to increased blood loss intraoperatively and it worsens the surgical field quality, thus prolongs the duration of operating time and increased bleeding can also predispose to complications. A significant landmark for localising the artery intraoperatively is identifying the ethmoid crest, which is located consistently anteromedial to the sphenopalatine foramen [11]. Study by Midilli et al. observed that SPA exists SPF as single branch in 60–75%, as two branches in 20–30% and three or more branches in less than 10% [12].
Laguna et al. [13] suggested that blood loss during ESS is strongly related to the disease severity and also on the anaesthetic agent used during the procedure. Patient with moderate to severe polyposis had increased bleeding compared to those with mild polyposis and sinusitis. Sreedharan et al. [14] observed that SPA block given prior to ESS was effective in reducing the intraoperative bleeding for first 2 h. Study by Ismail et al. [15] howed significant reduction in blood loss during ESS with bilateral sphenopalatine ganglion block. In this study, the cauterized side showed a marginally less blood loss than the non cauterized side, though this was not statistically significant.
Poor intraoperative surgical field reduces visualization thus makes identification of structures difficult and prolongs operative time. Laguna et al. [13] suggested that more severe disease requires increased operative time compared to less severe disease. In a randomised study conducted by Kesimci et al. [16] there is a significant increase in operating time noted in the group of patients received bupivacaine and levobupivacaine compared to saline in ESS. Psaltis et al. [17] described that Lund-Kenndey scoring system has high inter-rater and test–retest reliablility. Thus post operative outcome was measured using endoscopic Lund Kennedy scoring system as it provides valuable information by direct visualization of the cauterized area in the nasal cavity as well the other post operative changes like edema, scarring, crusting can also be noted. Though cases of increased crusting, re-bleeding, palatal numbness, inferior turbinate necrosis were reported in the literature with SPA cauterization, in this study no such complications were encountered. Study done by Rahman et al. [18] showed that symptomatic relief and quality of life improvement after ESS was compared by endoscopic Lund Kennedy scoring which showed patients with CRSsNPs had better life quality and symptomatic relief when compared with CRSwNPs.
It has been observed that SPA cauterization did not affect the per-operative blood loss in patients with CRS. The above results suggest that SPA cauterization is safe to perform in ESS. The limitation of this study is that the patients who underwent ESS had less severe disease and hence there was no significant difference in the amount of blood loss and the operative field. Similar studies in patients with more severe disease is recommended to evaluate the significance of SPA cauterization, in whom severe bleeding is expected and also longer follow up is required to assess the long term result.
Conclusion
This study evaluated the role of SPA cauterization in patients undergoing ESS for chronic rhinosinusitis. Endonasal SPA cauterization did not have a statistically significant influence on the visualization of the operative field during ESS and can be safely performed with no per-operative and post-operative complications or adverse events. Though marginal reduction in the amount of intra-operative bleeding during ESS is observed, this was not statistically significant. It is recommended that further large scale studies needs to be done to evaluate the efficacy of SPA cauterisation in those patients that have high-risk of moderate to severe bleeding during ESS.
Funding
None.
Compliance with Ethical Standards
Conflict of Interest
The authors declare that they have no conflict of interest.
Ethical Approval
Obtained.
Informed Consent
Obtained.
Footnotes
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