Endoscopic view of a hemostatic technique for endoscopic sinus surgery.

Regardless of whether local or general anesthesia is administered, hemostasis is important for good visualization and safety during functional endoscopic sinus surgery (FESS). (1) A systematic technique has been described that provides adequate and consistent hemostatic control during these procedures. (1,2)

Approximately 20 minutes before the patient is brought to the operating room, 0.5% phenylephrine is sprayed into the nose. Once the patient is in the operating suite, cotton pledgets saturated with 1:1,000 epinephrine are placed over the anterior and posterior ethmoid and sphenopalatine arteries. The pledgets remain in the nose for 10 to 15 minutes before any type of surgical dissection is performed.

Injection of 1% lidocaine with 1:100,000 epinephrine is carried out in a systematic manner at several sites (figure 1). The first injection is placed in the anterior aspect of the middle turbinate (figure 2, A). The second is placed superiorly near the insertion of the middle turbinate (figure 2, B). At this point, the surgeon will note blanching of the anterior face of the middle turbinate and the upper portion of the lateral nasal wall. The third injection is placed along the lateral nasal wall at the insertion of the uncinate process (figure 2, C and D). Here, it tnay become necessary to inject more than two sites. The fourth is placed into the anterior face of the ethmoid bulla (figure 2, E). The ethmoid bulla might not be visible if the middle turbinate is not retracted medially. The final injection is placed below the posterior end of the middle turbinate in the lateral wall of the nose in the area where the sphenopalatine artery enters the nose (figure 2, F). This area might be technically difficult to expose and might require the assistance of a long angled tonsil needle or a regular needle angled with a needle holder (figure 2, G). The needle tip is used to palpate the sphenopalatine foramen and is then advanced into the foramen or the area near the foramen. Aspiration must be performed prior to injection. (3) Injection near the sphenopalatine foramen into the lateral wall also has been found to be quite effective.

[FIGURES 1-2 OMITTED]

Some middle turbinates are highly vascular (figure 2, H) and might still bleed despite adequate injection, particularly during an anterior partial middle turbinectomy or resection of the lateral half of a concha bullosa of the middle turbinate (figure 2, I). In such cases, electrocautery might be necessary to achieve hemostasis. If bleeding persists at the end of surgery (which is extremely uncommon), a sponge can be placed under the middle turbinate in the operative cavity. (3)

The injection technique described here usually provides for reliable hemostasis during conventional and powered FESS procedures.

References

(1.) Kennedy DW. Functional endoscopic sinus surgery: Technique. Arch Otolaryngol 1985;111:643-9.

(2.) Christmas DA, Yanagisawa E, Mirante JP, eds. Powered endoscopic maxillary sinusotomy. In: Yanagisawa E, Christmas DA, Mirante JP. eds. Powered Instrumentation in Otolaryngology-Head and Neck Surgery. Ch. 5. San Diego: Singular, 2001.

(3.) Kennedy DW. Functional endoscopic sinus surgery: Anesthesia, technique, and postoperative management. In: Kennedy DW, Bolger WE, Zinreich SJ, eds. Diseases of the Sinuses: Diagnosis and Management. Ch. 16B. Hamilton, Ont.: B.C. Decker, 2001.

From the Section of Otolaryngology, Hospital of St. Raphael, New Haven, Conn., and the Section of Otolaryngology, Yale University School of Medicine, New Haven (Dr. Yanagisawa), and the Department of Otolaryngology, University of South Florida College of Medicine, Tampa, and Halifax Medical Center, Daytona Beach, Fla. (Dr. Mirante and Dr. Christmas).